Tag Archives: psychoanalysis

I recently emailed Dr. Lloyd Ross, a clinical psychologist from New Jersey with 40 years’ experience treating individuals labeled borderline. I asked him for his views on the DSM model of BPD, the causes of borderline states, what is the best treatment for BPD, and can it be cured. Here are highlights of his responses, with my emphases in bold:

Highlights of Lloyd Ross’ Viewpoints on BPD, excerpted from his essay below:

On therapists who don’t want to work with people labeled BPD:

Lloyd Ross: “To avoid their own discomfort, poorly trained therapists describe borderline individuals as untreatable. Well trained therapists do not have that opinion. Well trained therapists have done well with these individuals, provided the therapist knows both what to expect and what he is doing.”

On good outcomes for people labeled “BPD”:

Lloyd Ross: “With proper insight oriented therapy, people labeled as borderline do go out in the world and function quite well in relationships, employment, etc. Like the rest of us, the goal is not to be cured from some non-existent disease, but to simply resolve the issues in our development that stop us from functioning in a relatively comfortable manner.”

On BPD as a medical diagnosis:

Lloyd Ross: “(As a medical diagnosis) the only “borderline states” that have any validity for me are on the border of Mexico or Canada… In addition, there is absolutely no real science behind any of the DSM/ICD diagnoses.”

On how the word borderline can be useful:

Lloyd Ross: “To use the term “borderline” from a developmental point of view is very different… Using the term “borderline developmental issues” enables us to go back in time and try to help the individual to undo, modify, and soften development that did not go smoothly the first time around.

On the developmental approach to working with people labeled BPD,

Lloyd Ross: “Using this model, the therapist works toward a stronger continuum of emotional development so that a person can function in a more whole way. Borderline states are not a disease or medical issue and therefore, nobody is “cured.” People just learn to handle various issues in their lives in a smoother, more comfortable manner for them.”

On suicide prevention:

Lloyd Ross: “According to Bertram Karon, Ph.D., one of the world’s most prolific researchers on effective psychotherapy with patients labeled schizophrenic, suicidal, and borderline, ‘The best suicide prevention is effective psychotherapy.‘ ”

On the value of medication in treating people labeled BPD:

Lloyd Ross: “The medication approach (anti-depressants and/or anti-psychotics) is useless in people with borderline, suicidal, and PTSD symptoms. In fact, anti-depressants are probably one of the major causes of iatrogenic (doctor induced) suicide in this country in the past 15 years, especially with individuals labeled borderline.”

On trauma as the cause of borderline states:

Lloyd Ross: “The cause of “Borderline Personality Disorder” as with all of the “made-up” psychiatric diseases, is trauma at various times and stages in a person’s development… The failure of all-good and all-bad perceptions to fuse is the genesis of all pathologically borderline states.”

My Interaction with Dr. Ross

So (this is Edward writing again) these were my favorite parts of what Dr. Ross said about BPD; for the full context, see his essay below. I had originally found Dr. Ross because he is a member of ISPS, the International Society for Psychological and Social Approaches to Psychosis, with which I’m also involved. In my first email, I asked Dr. Ross for detailed answers to my questions about what causes BPD, what best treats it, is it curable, and how best to understand Borderline Personality Disorder. I wanted to see how much his viewpoints agreed with mine, and to share an informative and hopeful professional viewpoint on BPD with readers of this blog.

In response, Dr. Ross decided to write a single essay incorporating his responses to all the questions. That essay, “The Borderline States” forms the main part of this post. I highly recommend reading it to see how a psychologist who’s worked with over 100 people labeled BPD understands the condition. To Dr. Ross, thank you for taking the time and for giving me permission to post your essay here.

For anyone wanting to know more about Dr. Ross, he is a leading member of the International Society for Ethical Psychiatry and Psychology (ISEPP), and is listed halfway down this page: http://psychintegrity.org/isepp-leadership/

Lloyd Ross, Ph.D.

Dr. Ross also features in a Youtube interview about helping people labeled schizophrenic here: https://www.youtube.com/watch?v=wyL0jjI93OI . I want to note that Dr. Ross did not edit this video (the silly cartoonish elements, which in my opinion detract from its message, were added by the filmmaker Daniel Mackler). But you can see from the way Dr. Ross talks that he is an experienced, committed therapist.

Lastly, I want to note that Dr. Ross’ viewpoints appearing on my site does not mean that he endorses or agrees with everything else on this site. His viewpoints are his own. Here is his full essay:

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THE BORDERLINE STATES

By Lloyd Ross, Ph.D.

During my 40 years as a clinical psychologist, I have worked with approximately 100 to 150 people who would be considered to fall into the developmental framework of what psychiatry, in its simplistic and arbitrary way, views as borderline. These people were seen by me for at least one year or longer, some multiple times per week, and others once per week. Some were also seen at multiple times in their lives with months or years separating periods of therapy.

Before discussing this topic, I would like to make clear the issue of psychiatric diagnoses of “mental disorders.” I am a clinical psychologist who was psychoanalytically trained from an ego-developmental point of view. I have been in full time practice for almost 40 years and have always avoided psychiatric diagnoses, as I see the various recreations of the DSMs/ICDs as nothing more than an attempt to medicalize things that are not medical to begin with (human behavior, experience, and development). On that basis, the only “borderline states” that have any validity for me are on the border of Mexico or Canada.

In addition, there is absolutely no real science behind any of the DSM/ICD diagnoses. All of them were developed in committee rooms inhabited by mostly elderly white psychiatrists, many of whom represented the financial interests of the pharmaceutical industry. When I do write down a DSM or ICD diagnosis for a patient, and only at a patient’s request, it is usually because they need it to submit their claim to an insurance company (Unfortunately, that is the way things are in this society). The diagnosis I use is almost always “Post Traumatic Stress Disorder,” for several reasons:

It is the closest thing to a real diagnosis in the entire list of diagnoses, in that anyone who is having enough emotional difficulties to seek help has had personal trauma of some sort as one of the factors that caused their difficulties.

From a developmental point of view, the stage of development we are in or approaching when trauma occurs is a good predictor of how, when, and where it will manifest itself in a person’s life.

The term itself, “Post traumatic stress disorder,” is sufficiently vague and innocuous to the public to make the term less of a problem for an individual than terms such as schizophrenia, psychopathic or sociopathic personality or borderline personality disorder, none of which have any real scientific meaning.

I approach human (not medical) diagnosis as a strictly developmental issue. This is because of the influence of Margaret Mahler on my training, with some influence from Donald Winnicott, Edith Jacobson, Anna Freud, Renee Spitz, Heinz Kohut, and Ruben and Gertrude Blanck. I come primarily from Mahler’s framework and was supervised by her. Therefore, any real diagnosis that I do comes from an ego-developmental point of view.

The Causes of Borderline States

When looking at a detailed history of people commonly diagnosed by others as “borderline personality,” I and others have found that these people have experienced emotional trauma at around the time in development when children make and solidify their attachment to the mother figure. To be a bit more specific, it is associated with trauma during that time frame and there is always deprivation around that time frame also. I am sorry for making it such a complicated thing, but when you don’t simply slap a diagnostic label on somebody, but are instead dealing with a real live very unique individual and their complex developmental problems, the issues are no longer simple. In addition, to perceive a human being as literally being a diagnostic category—a “Schizophrenic” or a “Borderline” –dehumanizes that person.

The cause of “Borderline Personality Disorder” as with all of the “made-up” psychiatric diseases, is trauma at various times and stages in a person’s development. That is why taking a carefully detailed history of that person’s development, events in his life, and memories in his life is so important. All extreme mental states, whether with someone diagnosed as schizophrenic, borderline, neurotic, etc. which are meaningless terms, are the result of things gone awry or not having been negotiated at various stages in development, resulting in trauma.

Even if a child seems to progress just fine, if and when trauma occurs, it lingers or appears dormant. When, even years later, that trauma is reactivated by another trauma, that person seems to exhibit or feel the original trauma again without ever connecting the two. That is why I use the diagnosis “Post Traumatic Stress Disorder” with insurance companies, for everyone, and not just those who come for help. There is no human being that I have met who has never experienced trauma, although the ramifications for some are more disturbing than for others.

A Personal Example of Trauma

I will give you a vivid example of trauma in myself. From the time I was five years old, until I was ten years old, I was ordered by my parents to come home from school immediately, without lingering with my friends, to babysit my grandmother because I left school at exactly 3:00 P.M. and the lady who took care of my elderly grandmother left at exactly 3:00 P.M. My grandmother was a very nice roly-poly lady who only spoke Polish and Yiddish, was blind except for being able to see shadows, and was able to walk from her chair to the bathroom to the bed by feeling along the wall. I, on the other hand, did not speak Polish or Yiddish.

My grandmother was alone for the five minutes it took me to get home and I would run all the way because I was told that if anything happened to her, it would be my fault, a rather heavy burden for a five year old. I would sit with her in a second floor apartment with very little communication and stop her from trying to cook. I would lead her to the bathroom and to the bed so that she didn’t fall, and sometimes would make her tea, watching that she didn’t spill it on herself. Either my aunt or my parents would come home between 5:00 P.M. and 6:00 P.M., but quite often, they went shopping first or had something else they had to do, and I would be stuck with my elderly grandmother for two to five hours. Also, since she couldn’t see, she kept all the lights off to save money so the apartment was usually dark.

When I turned ten years old, I was offered a part-time job and because work was so important to everyone in the family, when I got the job, my babysitting for my grandmother was over. What I remember most about the babysitting was that everything was always dark and boring. One day, I was very bored, and I could hear my friends playing ball in the street below. I opened the window and sat on the ledge, playing catch with a friend who was in the street. Someone called the police because they thought I was a jumper and they yelled and screamed at me.

After getting three advanced degrees, and spending a year in a horrific war, I came home and met my wife to be. I was always relaxed, mellow and calm, yet at the same time I could be cutting and sarcastic, all of which I admired in myself. After getting married, several days per week I would work late and come home when it was dark. When the lights were on in my house, there was never a problem, but if I came home to a dark house, I would feel enraged and walk in complaining, arguing, and finding fault with everything.

Since I was in my own training analysis at the time, I brought it up, thinking it had something to do with my time in Vietnam. I finally made the connection between the rage that I felt when forced to stay in a dark house watching my grandmother, and the rage I felt when I approached my house with the lights off. Having made that connection, I no longer became enraged when the lights were off, but I didn’t feel wonderful either. My wife and I discussed it and she kept the lights on for me, just like motel 6. Another point is that learning the connections don’t necessarily take away all the feelings but they do put you in much better control of those feelings.

That is a relatively minor cause of Post-Traumatic Stress Disorder. Who is a victim of it? Everyone, unless their childhood was just perfect, wonderful and magnificent, and so far, I haven’t met anyone who falls into that category, although I never met Donald Trump.

Understanding Borderline States Developmentally

I would like to discuss development at this point because most of the people seen by psychotherapists fall into this particular phase, including those with the arbitrary junk-science diagnosis of borderline personality. In normal development, when a child approaches the end of the first year or year-and-a-half of life, he/she begins to recognize that he is not one with his mother, but is really a separate person. This infantile recognition marks the beginning of the end of the “symbiotic” phase of human development and the very beginnings of the “practicing” sub-phase, sometimes better known as “the Terrible Twos.”

The practicing sub-phase is an early part of what we often refer to as the “separation-individuation” phase of development, which is so critical to our development that Margaret Mahler describes it as “the psychological birth of the human being.” In fact, she wrote a classic book just about that phase of human development. During the practicing sub-phase, the child’s mission in life is to prove that he is a separate, autonomous human being, while at the same time not losing his mother. He does this by exploring his world, by trying to do things independently from his mother, and by oppositional behavior, (saying “NO”.)

Sometimes, this phase of development can seem like a battle against parental figures, hence the name “terrible twos.” Problems that develop in the early parts of this phase of development which a child is unable to successfully negotiate often result in what they call “borderline issues” because they develop during the beginnings of the quest for reality on the part of the child, which occurs right on the border of these two stages. Let me go on with a description of the next part of the child’s emotional development.

The Identification Process, Splitting and Fusion in Childhood Development

While beginning the Separation-Individuation phase of development, the child begins to identify himself with others. This is also the beginnings of object-relationships. Since the primary object for all of us is mother (whoever mothers us, which could be the actual mother or a mother-substitute) a child will view his mother in very black and white terms as he begins the identification process. Mother in her nurturing role is seen as “good mother.” However, when mother says no to the child, restrains him in some way or frustrates him, mother is then seen as “bad mother.”

From a child’s point of view, “good mother” and “bad mother” are really two different people. This view occurs because of the absolute black and whiteness of the child’s thinking process at this age and is a normal age appropriate distortion of reality. The process is called “splitting.” When mother gives me what I want, she is “good mother” but when she doesn’t give me what I want, she is “bad mother.” These are totally two different people to the child.

Over the next year or two, depending upon intervening variables as well as the child’s developmental progress, the image of the “good mother” and “bad mother” slowly start to come together in a merging process. At a certain point, these objects “fuse” and we no longer see our mothers as a split object, one mother good and the other mother bad. When these objects fuse into one object, one mother, we begin to entertain a different, more sophisticated perception of mother. Now, mother is seen as basically “good mother” who sometimes is not so good. However, both the good and the bad are housed in the same person.

This is a much more benevolent view of mother and allows for imperfection. Since mother is the “primary object,” the first person that a child identifies with, his perception of mother is vital to his perception of himself. Once the good and bad objects are fused, the extreme view of the child is softened. He now also looks at himself and is able to perceive that: “I’m basically a good child, but sometimes I do bad things. Even so, I’m basically a good child.” This benevolent perception does two things. First, it brings us in closer contact with reality, and secondly, it softens out perfectionism both toward ourselves and toward others.

When Fusion Doesn’t Take Place, or What Causes BPD

The failure of all-good and all-bad perceptions to fuse is the genesis of all pathologically borderline states.Please be aware also that I am using the word pathology to simply indicate development gone awry or developmental stages that were not properly negotiated by the child for multiple reasons.

Sometimes, due to external issues that limit or skew a child’s development, or because of internal developmental issues, a child is unable to fuse the good and bad objects into one unified whole. In that case, the split object remains and the child continues to perceive dual mothers; one totally good and one totally bad. Under such conditions, when the child identifies with the primary object (the mother or mother substitute) and then looks in the mirror, he sees either a totally good person or a totally bad person with no redeemable good qualities, a rather harsh view of oneself. Under the above conditions, the child’s development makes him a potential candidate for suicidal thoughts, feelings, and actions as well as borderline personality issues.

In the so-called “borderline personality, the core issues precede the problematic object relations and there are also introjective insufficiency problems with good and bad objects. Most people dealing with this issue feel an “annihilation panic” based upon the relative absence of positive introjects that pretty much explain the “borderline” person’s feeling that he is existentially at risk.

In other words, in the so-called “borderline personality, it isn’t just the all-good, all-bad splitting that is a problem, but the paucity or insufficiency of positive introjects. Therefore, in people who are labeled borderline, the negative introjects predominate. Also, in come cases, they are able to solve the introject problem by, in a sense, becoming their own object or mother, thereby being able to comfort themselves without the need for anyone else. In the psychiatric establishment, these individuals are referred to as “psychopathic” or “sociopathic” personalities. They don’t need mothering because they can self-comfort.

Let’s go back for a moment to clarify what the mother-introject is. In normal development, the child internalizes a mental representation of the mother figure and the way in which she makes the child feel. Negative introjects always come from abuse that has taken place at around this time. (Sorry if I am blaming the mother figure but that is the way it goes.)

Gerald Adler, also a student of the ego-developmental model, extends this work further. He describes ideal treatment as an attempt to establish and maintain a dialectic therapeutic relationship in which the therapist can be used over time by the patient to develop insight into adequately holding onto positive introjects. In this manner, the arrested developmental process is set in motion to correct the original developmental failure. This is called the “Deficit Model” in that the focus is on what is missing in that person’s development. Therefore, the core of borderline issues precede the destructive internal object relations. The issues involve abuse, the absence of a positive introject, and an overwhelming constant feeling of being at risk, primarily due to the insufficiency of positive introjects.

Treatment for the Borderline, Suicidal or PTSD individual:

In this section, I would like to consider a number of treatments for these people and then the treatment of choice.

Electroconvulsive Shock; (ECT):

ECT, in short, involves placing two electrodes on the skull over the frontal area of the brain and then administering voltage that is comparable to being hit by lightening. This does several things. First, it causes a brain seizure which is not very pretty to observe. To avoid looking like a scene out of the movie “One Flew Over The Cuckoo’s Nest,” psychiatrists first administer sedative drugs to mute the external manifestations of the electric shock such as thrashing, broken bones, etc.

However, when they do this, to cosmetically improve the look of the treatment, they also have to increase the voltage, thereby creating greater cell damage and cell death in the brain, flatness of personality and affect, and slower thinking processes. This damage is similar to what occurs as a result of long-term heavy alcohol use, only more rapidly and in more focused areas, particularly the frontal lobes of the cortex or the cognitive and feeling areas of the brain. Keep in mind that ECT is similar to a motorcyclist head injury or explosion in that it is a “traumatic head injury,” only it is being caused by a physician. One of the side effects of killing off brain tissue in the frontal lobes is apathy, flatness of personality and affect, and slower thinking processes.

As a result of all this brain damage, suicidal thoughts (all other thoughts as well) are deferred and drastically slowed up. Therefore, ECT may temporarily defer suicide or soften the borderline issues, but it does not prevent it and when a person slowly and partially recovers from the shock, he may realize the lesser functioning he is left with permanently, an even greater motivation for suicide. ECT also significantly and drastically disrupts any psychotherapeutic process that is being carried on. Earnest Hemingway was “cured” of suicidal tendencies by ECT.

Bio-psychiatric Treatments:

The medication approach (anti-depressants and/or anti-psychotics) is useless in people with borderline, suicidal, and PTSD symptoms. In fact, anti-depressants are probably one of the major causes of iatrogenic (doctor induced) suicide in this country in the past 15 years, especially with individuals labeled borderline. Also, feeding a patient cocktails of neuroleptic (anti-psychotic) drugs acts simply as a temporary chemical restraint, often called a “chemical lobotomy.” In that sense, these drugs mimic ECT. I do not consider either real help for any individual and they make insight oriented therapy almost impossible.

Insight Oriented Psychotherapy:

According to Bertram Karon, Ph.D., one of the world’s most prolific researchers on effective psychotherapy with patients labeled schizophrenic, suicidal, and borderline, “The best suicide prevention is effective psychotherapy.” He goes on to say: “Of course the most effective way to prevent a suicide or a homicide is to understand the psychodynamics and deal appropriately in therapy with these issues.”

There are also a number of things that need to be confronted in any psychotherapeutic situation with a suicidal, borderline, or homicidal patient. Among them are his anger and rage, his and the therapist’s loss of control, and in a child, the significant parental issues, the patient’s developmental history, the ways in which the patient transfers his feelings (mostly bad and angry feelings) to the therapist, as well as other issues.

From the therapist’s perspective, he must be able to handle the transferential rage and aggression as well as his own feelings of lost control and counter-transferential issues. Finally, the therapist needs to deal with his own fears of the patient’s potential for suicide. Untrained,

fearful therapists, when they hear that a person has suicidal issues, get frightened and immediately refer to a psychiatrist, as though a psychiatrist has some magical powers to treat this problem. Unfortunately, when a therapist does this, the message to the suicidal person is “I am afraid of you and am not equipped to deal with your issues. The therapist is then immediately written off by the suicidal person.

Many therapists also do not want to work with people diagnosed as borderline for two reasons. The first is the rage that gets directed at the therapist. Borderline development results in a huge need to get rid of the aloneness they feel which results in rage that makes the therapist cease to exist. The counter-transference from an untrained therapist is a feeling of “I’m wasting my time here.” The second is that the amount of support needed is greater than with other kinds of development. You cannot resolve splitting until a strong positive relationship exists between the person and the therapist. In treatment, the unrealistic idealization of the therapist that the borderline person feels must be slowly worked through and discussed before it is relinquished and replaced by a more realistic view. The therapist’s goal is to slowly build up the earlier foundations of the ego structure through the relationship so that what is established is a not-so-harsh superego and thereby, less black and white pain in the face of imperfections and losses.

It should be understood that using this model, the therapist works toward a stronger continuum of emotional development so that a person can function in a more whole way. It is not a disease or medical issue and therefore, nobody is “cured.” People just learn to handle various issues in their lives in a smoother, more comfortable manner for them.

A Brief Word on Narcissism

Narcissism is often a component of borderline development. Narcissists are particularly hard to treat. They find it difficult to form the warm bond with a therapist that naturally evolves with most other patients. Instead, they often become cold or even enraged when a therapist fails to play along with their inflated sense of themselves. A narcissistic patient is likely at some point to attack or devalue the therapist, and it is hard to have to sit with such people in your office unless you are ready to accept that.

But narcissism is not limited to the most extreme cases who make their way to the therapists’ office. A healthy adjustment and successful life is based to some degree on narcissism. Healthy narcissists feel good about themselves without needing constant reassurance about their worth. They may be a bit exhibitionistic, but do not need to play down the accomplishments of others to put themselves in a good light. And although they may like adulation, they do not crave it.

Normal narcissism is vital for satisfaction and survival. It is the capacity to identify what you need and want. Pathological narcissists, on the other hand, need continual reassurance about their value. Without it they feel worthless. Though they have a grandiose sense of themselves, they crave adulation because they are so unsure of themselves that they do not know they have done well or are worthwhile without hearing it from someone else, over and over. The deeply narcissistic person feels incomplete, and uses other people to feel whole. Normally, people feel complete on their own.

”Narcissistic vulnerabilities,” as psychoanalysts refer to them, make people particularly sensitive to how other people regard them. You see it in marriage, in friendships, at work. If

your boss fails to smile when you greet him it may create a withdrawn, anxious feeling. If so, your self-esteem has been hurt. A sturdy self absorbs that so it’s not unbalanced. But if you’re vulnerable, then these seemingly small slights are like a large trauma. On the surface, extreme narcissists are often brash and self-assured, surrounded by an aura of success. Indeed, they are often successful in their careers and relationships. But beneath that success, feelings of inadequacy create the constant need to keep inflating their sense of themselves.

If they do not get the praise they need, narcissistic people can lapse into depression and rage. Thus, many workaholics put in their long hours out of the narcissist’s need to be applauded. And, of course, the same need makes many narcissists gravitate to careers such as acting, modeling, or politics, where the applause is explicit. Many difficulties in intimate relations are due to narcissism. Marriage brings to the fore all one’s childhood yearnings for unconditional acceptance. A successful marriage includes the freedom to regress, to enjoy a childlike dependency. But in marriage, a couple also tend to re-enact early relationships with parents who failed to give them enough love. This is particularly hard on those with the emotional vulnerabilities of the narcissist. All narcissists fall within the borderline spectrum of development, but not everyone in the borderline range of development is narcissistic.

In summary, a therapist who is not trained well will usually not want to work with a borderline person for all the reasons mentioned above. To avoid their own discomfort, they describe them as untreatable. Well trained therapists do not have that opinion. It is not a “mental illness,” (disease.) Rather, it is a breakdown of a developmental phase that we all go through and involves issues such as splitting, negative introjects, probably early abuse, suicidal issues, and narcissistic issues.

Well trained therapists have done well with these individuals, provided the therapist knows both what to expect and what he is doing. Because it is not a disease, no one is cured. However, with proper insight oriented therapy, people labeled as borderline do go out in the world and function quite well in relationships, employment, etc. Like the rest of us, the goal is not to be cured from some non-existent disease, but to simply resolve the issues in our development that stop us from functioning in a relatively comfortable manner.

Finally, the term “borderline,” when used as a medical or psychiatric diagnosis, is both useless and harmful in that it is suggestive of some evasive disease. To use the term from a developmental point of view is very different and can be helpful in understanding what in a person’s development, was not negotiated properly or fully successfully. Using the term “borderline developmental issues” enables us to go back in time and try to help the individual to undo, modify, and soften development that did not go smoothly the first time around. This is something that is being done all the time by private-practice therapists, but not by what I call “the mental health industry.” However, that is a topic for some other time.

Below, I have listed a few books that should be helpful in understanding the treatment issues with individuals who are dealing with borderline issues. I have also included several books that support my opposition to the medical model approach.

Jacobson, E. (1954). “The self and the object world: Vicissitudes of their infantile cathexes and their influence on ideational and affective development.” The Paychoanalytic Study of the Child, 9, 75-127.

Jacobson, E. (1964). The Self and the Object World. New York: International Universities Press.

If you are looking for explanations of why borderline mental states develop, what keeps people stuck in them, and how to become free from BPD, please check out the pages above. In my opinion these object-relational approaches explain BPD’s etiology and how to become non-borderline better than CBT or DBT approaches. The latter approaches typically focus on short-term symptom management rather than transformation and cure of BPD.

Today’s post will add another approach, the Kleinian Approach to Borderline States. Kleinian theory focuses on the Paranoid-Schizoid Position and the Depressive Position.

What do these words mean, and why are they useful in understanding borderline conditions?

Melanie Klein: An Early Psychoanalytic Pioneer

To start with, why is this approach called Kleinian?

The Kleinian Approach to BPD is based on theories developed by Melanie Klein, an early 20th century psychoanalytic theorist. Klein grew up in Austria and received psychotherapy as a young woman from Sandor Ferenczi, a Hungarian psychoanalyst who was himself an innovator in understanding schizophrenic and borderline individuals.

Klein studied psychoanalysis in Berlin and London, eventually becoming a renowned therapist of emotionally troubled children. Working with children enabled her to see processes of all-good and all-bad splitting occurring live in the therapy sessions. Having often been severely neglected or abused, the children misperceived Klein as all-good or bad based on their past experience with “bad” parents and their need for a “good” parent-substitute.

Melanie Klein noticed that the more abuse and neglect the child had experienced, and the worse the relationship between child and parents, the more severe the splits in the child’s perception of the therapist tended to become. This meant that, despite the fact Klein tried to treat them well, children with worse parents tended to more unrealistically perceive Klein as an “all bad” mother figure. This transference (transfer of feelings from past people onto present people) is related to how borderline adults tend to misperceive potential friends or lovers as uninterested and rejecting.

Klein also noticed that as they improved in therapy, children who had initially utilized all-bad splitting became attached to her as a good parent figure, growing emotionally to the point where they could trust her and feel concern for her wellbeing (reparation). Children from healthier families often started therapy at this more advanced position, allowing Klein to observe a more positive mode of relating from the beginning.

From these two different ways in which the children related, Klein posited two primary orientations toward perceiving the world as seen from the child’s perspective. She called the first, developmentally earlier, more dangerous and isolated way of experiencing the world the Paranoid-Schizoid Position. She called the second, later, more secure and dependent orientation the Depressive Position.

These two positions can be understood as regions along a continuum of increasingly healthy and integrated personality development, the early, paranoid-schizoid part of which anyone can get stuck in given enough trauma and deprivation, and the later, depressive part of which anyone can reach given sufficient positive resources.

The Paranoid-Schizoid Position

The paranoid-schizoid position is the way of experiencing one’s emotional life that corresponds with what are commonly labeled “borderline” mental states or “schizophrenic” mental states. In my understanding, borderline and schizophrenic states of mind are not different in kind, but only in degree; schizophrenia represents a more severe version of the splitting, self-fragmentation, and primitive defenses seen in borderline states. As discussed in the many psychodynamic books linked to in earlier posts, both borderline and schizophrenic states are fully reversible and curable with sufficient help over a long period.

Back to the topic at hand. Why is the “paranoid-schizoid” position called that and what does it mean? The “paranoid” part refers to misperceiving external others who are neutral or mainly good as “all-bad”, as paranoid people tend to do, and the “schizoid” part refers to the tendency to withdraw and isolate oneself from meaningful emotional interaction with others, as people who feel threatened and unsafe tend to do. When a person’s entire personality is centered around misperceptions of others as “bad”, and when a person isolates themselves interpersonally in a way that tends to perpetuate these misperceptions by not allowing in good corrective influences, they are operating in a “paranoid-schizoid” mode.

The term paranoid-schizoid is not meant to be pejorative, only descriptive. I think a better, more empathic term for the paranoid-schizoid position in adulthood would be something like, “The Adult Worldview of the Traumatized Child”, so please keep that in mind when reading these labels.

To Klein, the paranoid-schizoid position represented the earliest way of experiencing the world for a young child who is trying to test whether or not the external environment is safe and supportive. If parents and other important relationships mainly nurture and protect the child, then the child’s mind will develop a feeling of basic trust in others and of basic security in the world. This security will help them gradually move from the paranoid-schizoid to the depressive position. If neglect, abuse, trauma, and excessive stress predominate during childhood and early adulthood, if bad experiences tend to outweigh good experiences, then the person will get stuck in or regress back to the paranoid-schizoid position. In experiential terms, such a person will continue to feel unsafe and to distrust others relatively indefinitely, and may not even know what they are missing.

Core Features of the Paranoid-Schizoid Position

The paranoid-schizoid position features:

Lack of basic trust in others’ good intentions (“the basic fault” as discussed by Michael Balint).

Predominance of all-bad splitting, i.e. viewing others as rejecting and oneself as unworthy.

Predominance of feelings of aggression and envy over love and gratitude.

High levels of anxiety, a constant feeling of insecurity at the core of one’s being (“ontological insecurity” as discussed by R.D. Laing).

Tendency to isolate oneself and withdraw emotionally and physically. Related lack of awareness of others as psychologically separate from oneself.

Lack of subjective sense of self.

Use of primitive defenses to block awareness of what a precarious emotional state one is really in, including denial, avoidance, splitting, projection, and projective identification.

My Emotional Experience of the Paranoid-Schizoid Position

These descriptions are highly technical and removed from real experience. So here is how I experienced the paranoid- position, i.e. the out-of-contact and ambivalent symbiotic phases, emotionally:

As my being a tragic, pointless character from Dante’s Inferno, The Myth of Sisyphus, or Kafka’s Metamorphosis, doomed to endlessly repeat the same self-defeating behaviors.

As being alive and dead at the same time – alive physically, but dead emotionally and dead because no one knew the real me.

As being unable to trust or confide in anyone, because nobody cared and nobody had time.

As waging a constant battle to keep my terror and rage controlled enough to survive.

As having no idea how normal people handled relationships and problems so easily, resulting in intense envy.

As continuing to live emotionally in “the house in horrors” (my name for my childhood home with its physical abuse).

As being a cork on a stormy ocean on which you could never tell where the next rogue wave was coming from.

As being very aware of negative inner thoughts and very unaware of what was going on around me. These bad thoughts felt to me like persecutory demons.

As having to preserve as much energy as possible to defend against potential threats and dangers. I often thought of myself as an emotional warrior, spy, antihero, or survivor.

As being willing to do almost anything addictive or distracting rather than feel the bad feelings and the lack of love.

As a vengeful, hateful, evil person who wanted to take revenge on those who hurt me and strike back at the world to feel some power and self-control (It is, I think, this type of paranoid-schizoid experience in young men that leads to many mass shootings).

These experiences are correlates of periods when the all-bad self and object images were mostly or fully dominant over the all-good self and object images. For many years this paranoid-schizoid nightmare was my predominant way of experiencing myself and the world.

Kleinian Theory Compared to Other BPD Models

The paranoid-schizoid position correlates with the following elements of other psychodynamic approaches to borderline states:

The Four Phases, the Structural Deficit, the Borderline-Narcissistic Continuum, and the Paranoid-Schizoid and Depressive Positions are all analogous ways of describing a continuum of early emotional development. They can be diagrammed as follows:

These “primitive” (meaning developmentally early) mental states are consequences of the quantitative predominance of bad self/object images along with a structural deficit or quantitative lack of positive, loving memories. In other words, they result when someone has many more bad than good experiences with other people, and/or when the absolute quantity of good experiences is severely lacking.

The lack of love in the past, combined with present fears that keep a person from getting help, can keep an adult frozen in the paranoid-schizoid position for long periods. In this situation, partly out of a fear of being totally alone or objectless, the person will maintain a closed psychic system of all-bad internal relationships which feel like tormenting inner demons, monsters, and ghosts. The paranoid-schizoid state can feel like an inner hell or prison.

How All-Bad Splitting Perpetuates the Past in the Present

The psychoanalytic writer James Grotstein discussed the persecutory inner representations of the paranoid-schizoid individual as acting like a “band of merciless thieves” or “gang of brutal thugs”. These internalized relationships attack the vulnerable part of the person that wants help by “warning” or convincing them that other people are untrustworthy, uninterested, dangerous, and rejecting, even though this may no longer be true in the present.

These all-bad identifications are seen when borderline people tell themselves, “I am worthless”, “Nobody wants to help me”, “Other people are always too busy”, “Things never work out for me,” and so on. There is sometimes a large grain of truth to the negative perceptions about others, but the individual also colors what they perceive and how they “self-talk” to make things seem worse than they are. In other words, they only perceive the all-bad aspects and spit out the all-good aspects of external reality. In this way they treat themselves as did people in the past who rejected or neglected them. This is what I call “perpetuating the past in the present.”

These paranoid-schizoid inner objects or memories can be understood as schemas, i.e. models of representing past experience in relational terms. These models actively (and often negatively) influence the ability to perceive reality accurately and to take action in the present.

Examples of Paranoid-Schizoid Experiences in the movies Psycho, Memento, and Beauty and the Beast

Several dramatic films illustrate how past attachments to “bad people” (and more importantly the internal memories and self-images based on them) block potential relationships to new good people and serve to keep a person in the paranoid-schizoid position.

1 – Psycho: Norman Bates, the main character in Alfred Hitchcock’s horror movie Psycho, exemplifies the paranoid-schizoid position. Because he fears his mother will be jealous,Norman is unable to tolerate the presence of Marion, the lovely young woman who comes to visit his motel. In reality Norman’s mother is long dead, her rotting body sitting in a rocking chair in the manor house. But her remembered voice is alive and well in Norman’s mind, guiding his actions and ordering him to kill off the threatening “good” Marion. Norman constantly experiences the paranoid-schizoid position, always feeling in danger and unable to trust outsiders.

While Norman is actively psychotic, a parallel process plays out in less disturbed borderline mental states. Norman’s acting out of the way he imagines his mother would reject his wish for a positive relationships is disturbingly similar to how some older borderline adults keep sabotaging potentially good relationships even after their abusive parents are gone.

Memories of disappointing interactions with parents and peers therefore “warn”, discourage, and forbid the borderline person not to trust and enjoy relationships with friends and lovers in the present, because if they do they would be betraying their past bonds to “bad” parents (for which they often blame themselves) along with risking rejection by the potentially good new person. These unconscious identifications with all-bad memories of others explain the repeated frustrations that many people labeled BPD have with keeping friends and sustaining romantic relationships.

2 – Memento: In the Christopher Nolan movie Memento, Guy Pearce plays a man, Leonard, suffering from an unusual problem: He cannot form any new memories. This disability occurs after he is beaten by thugs who killed his wife. Therefore, Leonard is unable to remember or trust anyone new he meets. He becomes at the mercy of others who take advantage of his limited memory. The constant sense of paranoia that Leonard exhibits, along with his great difficulty in discerning what is real and what is a deception, brings to mind the paranoid-schizoid mental experience.

People in severe borderline states experience similar difficulty in trusting others, usually not because they are amnesiac, but because they are terrified that being dependent and close will result in rejection or abandonment. In other words, they believe that the present will repeat the past, i.e. that new potentially good people will turn bad, just as parents and peers rejected them before. These inner identifications with bad objects (objects meaning memories of past experiences with others), combined with a lack of past good object experience to rely on, results in the extreme sensitivity to imagined rejections that borderline people experience.

I remember watching the Alien movies starring Sigourney Weaver as a boy and being terrified by the scenes where a human suddenly turned into a monstrous alien and devoured a fellow colonist. I think these scenes unconsciously reminded me of my father’s sudden transformations into a violent “monster” who physically beat me, which fed my expectation that other adults would turn on me if I trusted them.

3 – Beauty and the Beast – This classic Disney children’s movie features another example of the paranoid-schizoid position. Due to his selfish and unkind nature, the Beast has been condemned to live alone in his castle. He can only be redeemed if he learns to love, and earn another’s love in return, by the time the last petal falls from a magic rose. Rather than seeking someone to love him, the Beast becomes hopeless, withdrawing and isolating himself inside his castle. When beautiful Belle tries to penetrate his “closed psychic system” of all-bad expectations, the Beast is at first aggressive and untrusting, not believing that anyone could love his true self.

Gradually, the Beast is able to permit himself to be vulnerable and experience closeness with Belle. This move toward dependence, attachment, reparation of past harms done to Belle, and realization of the love he has been missing out on, represent the Beast’s movement from the paranoid-schizoid to the depressive position. Gaston and his henchman represent the all-bad objects that serve to impede reunion with the hoped-for good object, and the Beast must courageously fight them off to defend his loving relationship with Belle (i.e. to securely reach the depressive position).

The Reunion Adventure – The Transition from Paranoid-Schizoid to Depressive Positions

The timeless theme of reuniting with a lost good person by fighting past inner demons and their external representatives repeats in many classic stories, including Homer’s Odyssey, the Star Wars movies, the epic films Gladiator and Braveheart, Disney’s Aladdin and the Lion King, The Crow starring Brandon Lee, and the novel Ulysses by James Joyce.

To see the repeating narrative, the reader need only think of how the heroes in these stories are separated from those they love by evil forces (“bad objects”) before having to fight for reunion with the lost beloved person. Joseph Campbell provides many additional examples in his book The Hero with a Thousand Faces. This epic battle comes alive in long-term psychotherapy of borderline states, when the battle is to overcome all-bad projections onto the therapist in order to trust and depend on the therapist as a new good person who can help the client move from the paranoid-schizoid to the depressive position.

I don’t believe in the validity of these labels as distinct illnesses; rather, people should be viewed as individuals with strengths and deficits along a continuum of ego functioning. If they are used at all, labels like “borderline” should be viewed as a cross-sectional working hypothesis which loosely describes the problems a person has at a given time. Labels like borderline emphatically do not represent a life-long incurable illness. In my view, DSM labels should be abolished since psychiatrists are unable to use them as descriptions of pathological ways of relating with which people can work creatively and from which healing is possible.

Instead of something descriptive and hopeful, the labels become perversely distorted into “lifelong mental illnesses” which may have a genetic or biological cause. This is ridiculous since no evidence exists that these diagnostic labels are reliably discrete from each other, nor that biology or genes cause the behavioral, thinking, and feeling problems to which they refer. It’s offensive, harmful, and arrogant for psychiatrists to misrepresent problems of thinking, feeling, and behaving to vulnerable people in this reductionistic, pessimistic way.

Therefore I again encourage readers to consider dismissing labels like Borderline Personality Disorder from your mind. Instead, consider thinking of individuals as experiencing different degrees of borderline mental states at different points in time and of borderline states as being reversible and curable.

The Depressive Position and Healthy Personality Organization

Since much of psychology is focused on what is wrong, pathological, symptomatic, or immature, I now want to focus on maturity, wellbeing, and psychological health, using these questions:

How do many people become emotionally healthy, i.e. able to regulate their feelings and self-esteem, to work productively, to form families, become loving parents, have intimate friendships, etc.?

Are emotionally healthy people just born that way, or does childhood experience matter, and if so how much?

Why are healthy people not borderline?

How can borderline people become healthy?

These are complicated, contentious issues. In most cases the answer to the first three questions is that emotionally healthy people have had many more good than bad interpersonal experiences during childhood and early adulthood. Compared to people who are labeled “borderline”, healthy people usually had more opportunities for trusting, secure, long-term relationships with family, mentors, and/or friends.

These good relationships helped them to overcome the paranoid-schizoid position and the splitting defense – which when not prolonged are normal parts of every child’s development – and to develop the capacities for ambivalence, self-soothing, and intimacy. In one sense, emotionally healthy people were simply lucky – lucky as helpless children to be born into families where love and security were readily available.

I believe that that healthy adults usually had parents who, while they were not perfect, were good enough most of the time. They were “good parents” in the sense of empathically responding to the child’s needs, comforting the child when vulnerable, and supporting the child’s independent activities. These parents themselves usually had a considerable degree of healthy personality development; i.e. the parents themselves did not make heavy use of splitting, and were able to accurately perceive their children as mostly good and only slightly “bad”.

In other words, non-borderline parents tend to raise non-borderline children, and borderline parents are more likely to raise future borderline children. NAMI won’t like to hear that parents can cause BPD, but sometimes the truth hurts! As suggested by the ACE Study below, poor parents do more frequently raise “borderline” and “schizophrenic” children. That doesn’t mean poor parents are “bad people” or that they should be blamed for their children’s problems. Of course they shouldn’t.

Rather, the passing of abuse and neglect from generation to generation is a tragedy for which no one should be blamed, and the maximum amount of support should be given to such parents to help understand and change destructive patterns.

What evidence is there that childhood neglect and abuse correlate with increased mental illness diagnoses? The recent Adverse Childhood Events (ACE) Study of 17,000 people has explored the connection between childhood trauma and psychological disorder diagnoses. This study polled a large sample of people seen in hospital and medical settings to examine how frequently different childhood experiences co-occurred with physical illnesses and mental health diagnoses. The ACE study shows that childhood emotional, physical, and sexual abuse are directly linked to likelihood of both physical illnesses and psychiatric disorder diagnoses in a dose-response fashion.

In other words, the more abuse and neglect a person reports in childhood (a higher “dose amount”), the more likely a person is to be labeled depressed or schizophrenic in adulthood. In my way of thinking, more childhood abuse and neglect increases the chances that a child will become developmentally frozen in the paranoid-schizoid position and experience borderline or psychotic mental states as an adult.

Drawing from the ACE Study, one can deduce that the less frequent and severe are a person’s experience of childhood abuse or neglect, then the less likely the person is to experience “borderline” or “psychotic” mental states as an adult. Although the survey didn’t cover it, I’d bet that a strong group-level relationship exists between having had reliable, loving parents (as the child experienced and perceived them) and an absence of adulthood mental health diagnoses. It makes sense because families with less abuse and neglect also tend to have more love, safety, closeness, and support (I could be wrong about this, but I doubt it. Let me know what you think in the comments).

Further Sources on Healthy Childhood Emotional Development

I’ve now digressed again from the topic of healthy personality development. The point I’m trying to make is the obvious one that loving, secure human relationships are crucial to healthy personality development. Rather than discuss this in further detail, I wish to refer the reader to sources with more knowledge than I.

Some good writers on healthy emotional development, i.e. on what helps young people become navigate past the paranoid-schizoid position (avoiding borderline mental states) and enter the depressive position (and reach psychological maturity) are:

1) Donald Winnicott (e.g. Maturational Processes and the Facilitating Environment). Drawing on his experience as a English pediatrician-therapist, Winnicott wrote beautifully about the healthy emotional development of children. Winnicott viewed psychotic states, including severe borderline conditions, as the “negative” or mirror image of healthy emotional development. They illustrated for him what happens when healthy parenting and secure childhood emotional development break down or never become firmly established.

2) James Masterson (e.g. The Seach for the Real Self). The American psychiatrist Masterson wrote mainly about borderline and narcissistic personality problems but always discussed what happens in healthy development contrasted with borderline/narcsisistic development. Masterson explained how the borderline/narcissistic personality could become healthy via internalizing self-parenting functions that they had missed out on in childhood.

3. Heinz Kohut (e.g. How Does Analysis Cure?). German psychoanalytic pioneer Kohut developed the field of self-psychology, which emphasizes how crucial empathic parental responses are to the young child’s healthy emotional development. He developed the ideas of idealizing relationships (referring to how children need a strong, safe figure to protect them) and mirroring relationships (how children need a supporter for their independent functioning).

It is instructive to understand how these relationships fail to occur between parents and future-borderline children, and why such relationships do not immediately develop when borderline adults go to psychotherapy. From Kohut’s work one can see that if most borderline adults had received adequate mirroring and idealizing responses earlier in life, they would likely be normal, healthy people today.

4. Lawrence Hedges (e.g. Working the Organizing Experience; Interpreting the Countertransference). Hedges is a California-based psychogist who recasts schizophrenic and borderline disorders as “organizing” and “symbiotic” ways of relating. He has a beautiful way of writing about how certain “potentials” for relateness never get activated and become frozen in borderline and psychotic mental states.

In the link below, which is a free e-book download, the sections “Borderline Personality Organization” (pg. 98) and “A Brief History of Psychiatric Diagnoses” (pg. 175) may be of interest. Hedges’ writing is not about healthy personality development per se, but he constantly discusses what positive elements are missing in the relational development of psychotic and borderline individuals.

5. Allan Schore (e.g. Affect Regulation and the Repair of the Self, The Science of the Art of Psychotherapy). Schore is an American neuroscientist who writes about how reliable, secure attachments to caregivers are crucial to the developing child’s brain, and how attachments to parents directly modify how genes express or do not express themselves. Schore does fascinating brain scans showing how the child’s brain reacts to good and bad relational influences. He also shows why nature and nurture cannot be separated and quantified in such myths as, “BPD is 50% genetic.”

6. Ed Diener (e.g. Happiness: Unlocking the Mysteries of Psychological Wealth). Diener is a sociologist who researches how social conditions on a national level promote psychological wellbeing. Good parents and mentors are extremely important for psychological wellbeing, but factors beyond family relationships a lot too, like poverty, educational opportunities, diet and exercise, safety at a national level, freedom of speech, economic inequality, etc. Diener shows how these factors correlate with psychological wellbeing for national populations.

As you might guess, people in Iraq, North Korea, and Zimbabwe really are far less happy than people in Sweden, Australia, and South Korea. While advanced nations have their own problems, Diener shows how some poor countries suffer such severe instability that they are almost “paranoid-schizoid” worlds, in which people constantly feel threatened and are unable to actualize their potential for wellbeing.

Compared to the simplistic, symptom-focused descriptions of Borderline Personality Disorder in the DSM , I believe so much more can be understood from these etiological depth approaches to borderline conditions and healthy emotional development.

Returning to the Kleinian theory, how does the Depressive Position fit into healthy emotional development?

Key Characteristics of the Depressive Position

The Depressive Position, although it might sound negative (like “depression”) actually refers to increasing psychological attachment, closeness, and maturation. It was called “Depressive” because Melanie Klein focused on how the young child experienced guilt, depression, loss, and increased concern for their parents’ wellbeing as they emerged from the paranoid-schizoid position. These “depressive” feelings emerged as the child became more aware of the mother as a separate person and realized how their actions could negatively affect her.

But the real thrust of the depressive position lies in these characteristics:

Increasing security in positive emotional attachments to other people (development of basic trust).

Predominance of all-good splitting followed by capacity for ambivalence.

Increasing awareness of others as psychologically separate from oneself.

This link from the Melanie Klein Trust explains the depressive position in more detail.

My Experience of the Depressive Position and Therapeutic Symbiosis

As stated before, a lot of these descriptions are technical and removed from real experience. So here is how I experienced the early part of depressive position, i.e. therapeutic symbiosis, emotionally:

As the end of a war in which I was a survivor emerging from the ruins, realizing that the whole battle had been going on in my mind, not the outside world.

As an incredible realization that I was not in danger, people could be trusted, the world was safe.

As emerging into real life after years in emotional hibernation.

As seeing the world and other people in color for the first time.

As “the halcyon (blessed) days”, my term for this period in my diaries.

As the sense that everything was right between me and my therapist, that I was like a blessed child and she was like a loving mother.

As a regression to being the playful, carefree child that I had never been able to be in my actual childhood.

As an overpowering sense of loss about how many years had been lost to misery and fear because of my parents’ abuse.

As feeling like a savior because I had saved myself by finding good people, just like the Beast found Belle to free himself from the curse.

As a feeling that I had become a self, a real spontaneous person for the first time.

As being able to enjoy other people and experiences, finally.

These feelings are correlates of the period when all-good self and object images begin to outweigh all-bad self and object images, i.e. the phase of therapeutic symbiosis as described by Harold Searles. In this stage the formerly borderline person achieves a healthy narcissistic level of object relations and reaches the depressive position.

Why Don’t Some People Reach the Depressive Position?

In severe borderline mental states, a person remains fixated psychologically in the paranoid-schizoid position as described above. Viewed from various vantage points, the borderline person tries to become healthy, functional, securely attached, and able to regulate their feelings but may fail because:

They have a quantitative deficit of internal positive memories that healthy people use to soothe themselves (Adler’s structural deficit), but don’t yet have the resources in their daily life (friends, family, therapist, etc) needed to repair this deficit.

They are simply unaware of the positive relationships they are missing (Searles’ out-of-contact state).

They are scared of trusting and depending on others due to past trauma which they fear new people may repeat, and thus choose to remain attached to their internal all-bad relatoinships (Fairbairn’s object-relations model of the attachment to the bad object, Searles’ phase of ambivalent symbiosis).

Their use of primitive defenses like denial, avoidance, acting out, projection, projective identification, leads them to unconsciously repeat self-destructive patterns.

This is only a brief attempt to answer the question about why some borderline individuals remain in the paranoid-schizoid position. I am still optimistic that healing and progress out of the paranoid-schizoid position is possible with appropriate insight and help.

Final Thoughts On Recovery From Borderline States and Progress to the Depressive Position

My own experience and research suggests that the single most crucial thing for recovering from borderline states in a long-term, dependent, loving relationship with somebody. It could be a therapist, a friend, a family member, or some combination of these. Feeling safe and loved by others for years is what enables children to become healthy adults, and it is also what enables once-borderline adults to become healthy adults. There is no substitute for internalizing the self-soothing and self-organizing functions of a loving, mature outside person. As I described in an earlier article, I experienced these healthy relationships for the first time with my therapist and a few key friends.

In normal childhood development, there is a “healthy” or normative paranoid-schizoid experience called the practicing phase, in which the child jubilantly explores the world and is relatively unaware of mother’s separateness. For most children, the parents and environment are supportive enough that the children don’t get stuck in a pathological paranoid-schizoid position that later becomes a borderline adult mental state.

Rather, most healthy children progress out of the normative paranoid-schizoid position into the depressive position at a relatively young age. These children are unlikely to regress and become borderline unless they encounter some overwhelming prolonged stress in later life. For children who are constantly neglected and abused, the risk is much greater that they will psychologically retreat and stay in the pathological paranoid-schizoid position, which leads to experiencing a chronic borderline or psychotic mental state in adulthood.

Again, it should be remembered that “normal”, healthy people would often have become borderline adults if they had experienced sufficiently severe abuse and neglect in earlier life. In Kleinian terminology, anyone can get stuck in the paranoid-schizoid mode of functioning when subjected to enough prolonged stress. People opearting in borderline mental states are not fundamentally different than the rest of us – they are just as human, but more unlucky in some ways.

With sufficient insight and resources, borderline people can become weller than well, i.e. become free from borderline symptoms, study and work productively, have intimate friendships and relationships, and experience joy and meaning. After they have become psychologically mature, life challenges still present themselves, but former borderlines can handle them with confidence as the capacities for ambivalence, regulating feelings, and maintaining self-esteem are developed in the depressive position.

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I welcome any correspondance at bpdtransformation@gmail.com

If you are struggling with BPD yourself or are trying to help a borderline individual, I would be happy to listen to your story and provide feedback if possible. Feel free to provide constructive criticism of this site also.

This article is the opinion of a non-professional layperson, and should not be taken as medical advice or as the view of a therapist who is professionally qualified to treat Borderline Personality Disorder or any other mental health condition. Readers should consult with a qualified mental health professional before undertaking any treatment.

For the purpose of understanding psychiatric problems in a more nuanced and optimistic way, here is a diagram from Donald Rinsley’s book Treatment of the Severely Disturbed Adolescent:

Please click on the picture to see it larger. Each row corresponds vertically to the rows above and below in describing degrees of emotional development, and each row describes emotional growth over time from left to right. The majority of the text in brown is Rinsley’s own diagram; the bottom additions in white are mine.

Donald Rinsley was among the most respected authorities on borderline and narcissistic conditions in the second half of the 20th century. He was a psychodynamic therapist who ran a psychiatric hospital for severely troubled adolescents in Topeka, Kansas in the 1960s, 70s, and 80s. He later worked extensively with personality-disordered and psychotic adults in an outpatient psychotherapy practice.

I believe that much can be learned from studying Rinsley’s diagram. It explains how psychiatric diagnoses were originally understood in psychodynamic theory – as problems in relating and functioning that occur along a continuum of severity and merge into one another. In other words, psychiatric conditions are not distinct disease entities; there are no clear lines that separate one from another.

At the upper and lower ends of each “disorder”, one cannot confidently say that a person is, for example, a higher level borderline versus a lower-level narcissist, since the conditions fade into one another. Note how the arrows denoting each region don’t stop before running into each other; they overlap.

In this row, Rinsley lists phases of healthy child development that, when interrupted, can cause arrests in emotional development – i.e. psychiatric problems. Roughly, autism (which does not refer to autism as understood today) refers to the earliest period when a baby is unaware of the external world and feels fused with its mother at a body-level. Symbiosis is when the child starts to relate in a back-and-forth need-fulfilling way with its mother.

During differentiation, the baby realizes that it is separate from its mother psychologically as well as physically. In practicing, the child discovers and explores the external world via its newfound ability to walk. And in rapprochement, the child develops a good relationship to the mother as a separate person and faces conflicts around dependency/attachment and independence/autonomous functioning.

In these descriptions, “mother” is synonymous with “caretaker”, “parental figures”, and “the external world of people”. In the object constancy phase, the mother is finally perceived as a mixture of good and bad qualities, meaning that splitting is overcome,, and the child is increasingly able to regulate their emotions. It is this achievement that is lacking in borderline conditiions. For progression through these phases to occur, it is crucial that good-enough mothering be consistently available; otherwise the child can get “stuck” in a certain phase.

There is one area where I disagree with Rinsley. I don’t think it’s possible to put the phases of infantile development into a neat timeframe (as Rinsley attempts to do by saying that object constancy takes over in healthy toddlers at around 24 months, for example). I think children’s development is highly individual and that aspects of these phases continue to be worked on long after the first few years of life, even in emotionally healthy children.

Row 2: States of Self-Object Fusion or Differentiation

In this row, Rinsley indicates whether a person sees themselves and others as fused (indistinguishable from each other; this is a psychotic state), split (self images experienced as separate from images of other people, but viewed as all-good or all-bad, a borderline state), or integrated (seeing a mix of good and bad qualities within both self images and images of other people, a neurotic/healthy state). Roughly, fused self/object images relate to “psychotic” states, split images to “borderline” or “narcissistic” states, and integrated images to “neurotic” or healthy states of minds.

Row 3: Specific Diagnostic Categories

Here Rinsley lists diagnostic labels that correspond vertically with the phases of child development and self-object differentiation from the higher rows: Autistic-presymbiotic schizophrenia, symbiotic schizophrenia, bipolar disorders, borderline personality, narcissistic personality, neuroses, etc. I will not describe specifically what these diagnoses mean; the reader who is familiar with DSM categories will recognize them.

The crucial thing is that the diagnoses overlap along a spectrum and thus are not distinct illnesses. Rinsley conceptualized diagnoses as morphing into one another as treatment progressed; for example, one could start treatment at an upper-level schizophrenic, become a “borderline” a year or two later, then become narcissistic, and finally end up functioning at a neurotic, essentially healthy level after several years.

As conceived by Rinsley, diagnoses never represented fixed “illnesses” that one had to have for life. Treatment could change diagnosis; there was the prospect of transformation. American psychiatry has fallen far from this viewpoint with its current pessimistic views of rigidly separate “mental illnesses” that one can only “manage.”

This reminds me of how many years ago, I attended a National Alliance of Mental Illness meeting. At this session people talked about how mental illnesses were “brain diseases” that one could “learn to live with”. Even back then I thought that was a pathetic, limiting idea. Who wants to just “manage their illness” when they could become truly well? Having realistic hope that one can transform oneself is so much more motivating! In my opinion NAMI is not to be trusted, due to their reliance on drug company funding. This funding implies a tie to the hopelessness of the disease categories of modern-day psychiatry.

Row 4: Major Diagnostic Categories

Here Rinsley lists the broad diagnostic regions: firstly, psychoses, which include schizophrenias, bipolar disorders, and some lower-level borderline conditions. These conditions represent emotional arrests in the earliest developmental periods. They include people who have fused images of themselves and other people; i.e. the person cannot distinguish between themselves and other people at an emotional level (and they see themselves and others as all-good and all-bad).

The second group is characterological (personality) disorders. These include the borderline, narcissistic, and also schizoid disorders. These also exist on a continuum and flow into one another. They feature splitting as their primary defenses Such people can emotionally perceive differences between themselves and other people, but they still see themselves and others as all-good or all-bad. The shorthand “G (S O)” with the space behind S and O mean that good self and object images are perceived as separate from each other, but are not integrated with bad self and object images. By contrast, in the psychotic conditions, with S-O, the dash between S and O means that the person experiences a lack of separation or differentiation between images of themselves and other people; they cannot emotionally tell where they end and other people begin. This “fusion” phenomenon occurs in some people who gets labeled with severe borderline conditions, which are partly psychotic, but it is a chronic condition in schizophrenic states.

Finally, in the last major diagnostic group, the psychoneuroses, the psychic structure gets reorganized so that splitting is eliminated and the person can see good and bad qualities coexisting in both their self-image and in their images of others. The shorthand S (G B) means that good and bad qualities are perceived together in oneself and others without splitting.

Row 5: Quality of Internalized Self-Object Images

This row describes how supportive or comforting the person’s internalized images of other people are. The more positive experiences a person has had, the further to the right hand of this continuum they are likely to be. Unstable archaic images refer to states where a person feels psychologically unstable because they are not comforted by sufficient positive memories / internalized good experiences. This corresponds to psychotic conditions and to lower level borderline states. This deficit is the reason for the commonly cited inability to regulate emotions in Borderline Personality Disorder. I wrote about this in my article on Gerald Adler’s insufficiency model:

The “stable archaic introjects” refers to when a person uses splitting, but the positive images are predominant most of the time over the negative, so the person can regulate their feelings better. This corresponds to higher level borderline and narcissistic conditions.

Lastly, differentiated self and object states refer to the ability to see good and bad in the same self or other-image. In this way people can consistently be perceived as mixtures of good and bad. This makes truly mature relationships possible based on genuine caring and interest in the other person, as opposed to mainly using people for what they can do for you (as with narcissistic conditions), or being so deficient in supportive introjects that one has trouble comforting oneself or trusting others at all (as in borderline and psychotic states).

In this row, I listed Jeffrey Seinfeld’s four phases in a way that corresponds vertically to the horizontal continuums in the rows above. Borderline states are associated either with the upper part of the out-of-contact phase, or more frequently, with the ambivalent symbiotic phase. As one progresses into the therapeutic symbiotic phase – corresponding to being able to trust and feel supported emotionally by other people consistently – one stops being “borderline” and progresses toward healthier narcissistic and neurotic levels of functioning. It occurs to me that it’s too bad these words still sound pathological and negative. Again, we need better words to describe challenges in relating and functioning, words to give people hope of becoming fulfilled and well, not just managing an “illness”.

Please see the article below for a detailed description of Seinfeld’s four phases. Understanding the relative strengths of positive and negative self/object images explains how schizophrenic states can evolve into BPD, which can evolve into NPD, which can evolve into neurosis/healthy personalities, etc. Really, all of these conditions represents problems with adapting and managing life problems; rather than “brain diseases” Given sufficient support, all of these conditions can evolve or morph into one another along the left-to-right continuum of emotional growth. Here are Seinfeld’s phases:

And here is an example of how a young woman progressed through the four phases, starting in the lower-level out-of-contact “borderline” phase”, progressing through the narcissistic phase, and finishing in the neurotic-healthy part of the spectrum:

In this row, I put common DSM labels – schizophrenia, BPD, NPD, neurosis, etc. These are not truly valid illness categories, but they have some meaning if understood as part of a developmental continuum.

Below these labels, I put Lawrence Hedges’ descriptions of the four developmental levels which Seinfeld described in his phases. I haven’t written about Hedges yet, but he is my favorite psychodynamic writer along with Jeffrey Seinfeld. His descriptions of people’s problems are much more empathic, human, and hopeful than the DSM labels. More on Hedges in a later post.

My goal in this article was to give the reader a taste of how psychodynamic theorists think about schizophrenia, borderline, narcissistic, and neurotic-healthy mental states as existing along a continuum of emotional development. This viewpoint is different than the rigid DSM categories which dominate American psychiatry today.

In my opinion, this spectrum or continuum based approach, while not perfect, is more informative and realistic than rigid DSM categories. Since it is developmental, it implies the hope that one can grow beyond frozen emotional development to become emotionally mature. That’s why it’s my rough guide for thinking about “borderline” and “narcissistic” states, although I try not to use those words too much!

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I welcome any correspondance at bpdtransformation@gmail.com

If you are struggling with BPD yourself or are trying to help a borderline individual, I would be happy to listen to your story and provide feedback if possible. Feel free to provide constructive criticism of this site also.

This article is the opinion of a non-professional layperson, and should not be taken as medical advice or as the view of a therapist who is professionally qualified to treat Borderline Personality Disorder or any other mental health condition. Readers should consult with a qualified mental health professional before undertaking any treatment.

A few months ago I discussed Gerald Adler, a clinician who treated BPD using a psychodynamic method. Today I’ll write about Jeffrey Seinfeld, the New York-based social worker who pioneered a Fairbairnian approach to Borderline Personality Disorder.

On this blog, it has been discussed several times how psychodynamic therapists have already “cured” BPD. Here is an example of a borderline patient’s recovery from Jeffrey Seinfeld’s book, The Bad Object.

I thought the reader might be interested to hear in detail about one of the “successes” in BDP recovery that are often referenced on this blog. Her story shows how complex, challenging, and interesting the journey may sometimes be. Some of this account is paraphrased, while the parts in quotations come straight from the text:

A Case Study: Kim (from The Bad Object, pages 101-123)

At the start of her therapy with Jeffrey Seinfeld, “Kim” was a 22-year-old Irish-American young woman. From ages 17-22, she been in regular treatment with another therapist, but had made little progress. After dropping out of high school at age 16, Kim lived at home with her mother. She did not work or attend school; rather, much of her time was spent abusing alcohol and illegal drugs.

With her first therapist, Kim showed no motivation to change, and indeed would boast about antisocial and destructive behavior, including tempting friends trying to quit drugs into again using them. She would regularly miss therapy appointments without calling to cancel. Her therapist as the time described her attitude as, “Who can blame me for messing up with all I’ve been through?”

Eventually, Kim’s first therapist referred her to Jeffrey Seinfeld. He had not lost hope for her, but felt that they had reached an impasse and that a change of approach might help her. Seinfeld scheduled Kim for twice-weekly appointments at a social-work center. For the first year or so of their work, she continued to regularly miss appointments without cancelling ahead, and to abuse drugs and alcohol regularly.

Kim’s Early Childhood

Seinfeld describes Kim’s childhood in this way: “Kim was an only child in an intact family. Kim’s mother alternately neglected and overindulged her. During Kim’s first year of life, her mother often ran out of the house to escape a psychotic husband… The mother would promise to return later in the evening, but often stayed away for days at a time. Kim therefore had repeated experiences of awakening to find herself abandoned by her mother. She grew to hate falling asleep if her mother was present, and she had frequent tantrums, insisting that her mother sleep with her…”

“Kim’s psychotic father had delusions that he was Jesus Christ and that demons possessed him. He underwent psychiatric hospitalization, and his condition was finally stabilized with psychotropic medication. Kim’s mother went to work when Kim was 3 years old, leaving her at home with her father, who was on disability. He would ignore her as he read the Bible or sat in a catatonic-like stupor. If she disturbed him with her romping and playing, sometimes designed to get his attention, he would beat her…”

“Throughout childhood, Kim was on a merry-go-round in her relationships with her family members. First she would side with her mother against her father. When her mother upset her, she would go to her father and side against her mother. When her father upset her, she’d go to her grandfather and side against everyone. As an adolescent, Kim took no interest in learning at school but instead “hung out” with peers and smoked marijuana daily. She dropped out of high school at the age of 16.”

Kim’s Early Therapy – The Out of Contact Phase

Seinfeld described how Kim’s life had little structure outside of her regular abuse of alcohol and drugs. She had trouble sleeping at night, and often slept during the day instead. Kim could not bear to be alone, and would often call her drug-abusing friends from high school to chat at all hours of the day. However, these friends were becoming less interested in her as they grew older and got jobs or moved away.

Kim felt that people were always too busy for her and would eventually abandon her. Thus, according to Seinfeld, her internalized bad object was a “busy object” who did not make time for her. Kim projected this image onto outside people based partly on experience with her real mother, who often did not take time to care for her.

Seinfeld notes that his main experience in relation to Kim early on was that she was oblivious to him psychologically. Seinfeld felt that Kim was unaware of his separate presence, but simply “told him stories” about her adventures with drugs, friends, alcohol, and other adventures. She did not expect any help, understanding, or admiration from her therapist. Referencing the out-of-contact phase, Seinfeld stated, “My position as an object was that of a witness as opposed to an admirer.”

After several months, Kim showed the first sign of becoming aware of Seinfeld’s intent to help when she wrote about him in her diary. She felt concern that her life was “going nowhere,” and wished that she could work or attend school. Shortly after this awareness, Kim cut her wrist with a razor. Seinfeld describes how “the self-mutilation is an antidependent attack against the vulnerable, libidinal self’s expressed need for an internal holding object. The antidependent self thereby reestablishes a closed, internal, invulnerable position.” In other words, the patient identified with how people rejected her need for help and support in the past, and repeated the same behavior toward herself in the present, acting as the bad parent and punishing herself (the bad child) inside her own mind.

This early phase of Kim’s treatment was an “Out of Contact” emotional phase, as described here:

Seinfeld acknowledged noted how Kim’s life was in reality extremely difficult. Her “friends” were self-absorbed and did not truly care about her, she had little support from her parents, and she had no structure in terms of a work or academic program, in addition to addictions to drugs and alcohol.

However, despite these severe difficulties, Kim did not respond by looking for positive ways out of her predicament. Rather, as Seinfeld describes,

“Kim was constantly preoccupied with how her friends and family exploited, rejected, and did not care about her. She would dwell on the rejecting object and rejected, unimportant self-image through the day and so would remain in a depressive, victimized position… Even when the external person did not in reality reject her, Kim would interpret the situation as rejection…. All of this is not to say that the external objects did not often treat Kim badly; on the contrary, they often did. But Kim had her own need to perpetually activate the all-bad self-and-object unit.”

Seinfeld noted that if one person in her life disappointed her, she would flee to a different person, but then find them equally disappointing. For example, Kim would go from her too-busy mother, to her drug-abusing and neglectful boyfriend, to her psychotic father, to friends who were moving on with their lives and did not care. Frustrated by each of these people, Kim comforted herself by using drugs, alcohol, and by stealing her mother’ car and “joyriding” despite not having a license.

Seinfeld said that none of his interpretations of her self-destructiveness worked at first. He stated,

“Throughout the first of fourteen months of her treatment, she seemed relatively out of contact with mer. She would recount her adventures and seemed to expect nothing from me but my continued presence… There was no spontaneous, gradual shift in her relatedness. She continued to miss sessions at the same rate as characterized her previous (five year) therapy… She used my empathy to justify her “who can blame me” attitude.”

The Safety of the Bad Object

Seinfeld began to intervene with Kim by gradually making her more aware of how her feelings of rejection and worthlessness were caused not only by the actual behavior of other people, but by how she responded to and interpreted their actions. Seinfeld states, “When she described a bad experience in reality, I empathized with how she felt but then shifted the focus to what she was doing to herself in her mind with that experience. It was not difficult so show that all of the external people she discussed reflected one image – that of rejection in relation to her own image as rejected.”

Seinfeld notes how Kim eventually became aware that she continually maintained a negative pattern of thinking and expectation about others, even when nothing happened in the outside world to justify such thinking. Seinfeld commented to her that such dwelling on negativity might occur because it felt safer to Kim to feel rejected than to feel accepted.

Seinfeld also beautifully described how, “I listened to all that she said and commented from the vantage point of the activation of internal object relations units. I listened to this patient as one would follow the stream of consciousness in a novel by Joyce or Proust, in which reality is always brightened or shaded by the narrator’s internal vision and experience. Kohut (1984) has suggested that such novels reflect the fragmented sense of self in severe psychopathology. One does not ignore external reality from such a vantage point; rather, close attention is given to the subtle but constant interplay between internal and external worlds.” In other words, when listening to a borderline patient speak, the skilled therapist constantly tries to perceive how reality is distorted or “colored” in a positive or negative direction by the patient’s splitting defenses.

Ambivalent Symbiosis

Seinfeld notes that the foregoing work gradually move Kim toward an ambivalent symbiosis. She gradually became aware that Seinfeld cared about her and wanted her to get better. For the first time, Kim asked her therapist in subtle ways about whether he was interested in her viewpoint. She was no longer only telling stories or complaining about abuse. She would ask Seinfeld if he felt that her mother and boyfriend cared about her. She wanted to know if Seinfeld understood the desperation and uncertainty she felt. Seinfeld described how Kim displaced many of her wishes for closeness and support from him onto the mother and boyfriend, because it was initially too threatening to get close to Seinfeld and trust him directly.

The relationship now assumed a stormy, emotional, push-and-pull quality. Kim would want support from Seinfeld but then be angry that she only saw him occasionally for therapy. She wanted him to understand her feelings about her family, but then criticized him as overly intellectual and detached. She became jealous that Seinfeld’s own family own family got most of his time and love, while she only got the leftover scraps. Outside of sessions, she began to cut down on her drinking, but then would return to it when she felt that two hours a week with Seinfeld was inadequate. She would perceive Seinfeld, “sometimes as a saint and at other times as a psychotic with delusions of grandeur, like her father.”

Seinfeld therefore described how Kim tried to take in his support and acceptance, but would then reject it, both due to her familiarity and loyalty to the rejecting object and to her fear of vulnerability and openness toward the good object. For example, Kim asked Seinfeld for help with getting a referral to a doctor who worked in the same hospital as Seinfeld for a minor medical problem. When Seinfeld responded helpfully, she rejected the referral as inadequate by viewing the doctor negatively. This related to her being threatened by feeling that someone truly cared about her.

At this point, Kim began attending therapy regularly and never missed sessions, even becoming upset if she was forced to be late. Rather than being upset with her mother or friends as often, she became intensely upset with Seinfeld if he did not meet her demands for caring and empathy in a perfect way. Despite Seinfeld making extra time to talk to her on the phone outside of regular appointments, she would become angry when he eventually had to leave to go see his family. She viewed him as a “too busy” bad object just like her mother and friends had been the “busy bad objects” before. She again felt angry with Seinfeld for expecting her to depend on him for support, but having only a few hours a week to spend with her. She continued to alternately view him as a caring, supportive person whose help she desperately wanted, and then suddenly to transform him into a too-busy, uncaring, impersonal therapist.

Seinfeld comments on this ambivalent symbiosis in the following way:

“The patient activates the all-bad self-object unit to defend against internalization of the positive self and object unit. The insatiable need serves the antidependent defense. By making her need for contact with the external object insatiable, the patient can perceive of herself as rejected regardless of the external object’s behavior. Therefore, the patient is always able to think of her needs as being unmet, to think of herself as rejected and of the object as rejecting. The activation of the all-bad self and object unit results in depression and rage. Insatiable need, the oral self-exciting object relationships (e.g. use of alcohol while rejecting a truly supportive other), is then activated to counter the depression and rage. In this regard, the all-bad self-object relations unit becomes a vicious cycle constituting both the rejecting and exciting objects… Insatiable need serves to maintain the perception of the object as rejecting in antidependent defense. This patient succinctly stated the antidependent position, “If I don’t think you like me, why should I bother to like you?”

In other words, it’s necessary to understand how the patient is an active agent in perpetuating their view of the therapist and others as rejecting (creating an impossible-to-fulfill, or insatiable need) rather than potentially helpful and positive.

The Transition to Therapeutic Symbiosis

Seinfeld now constantly remarked upon the ways in which Kim focused on the ways in which he (Seinfeld) was not available because this felt safer and more familiar than focusing on the ways in which he was available. Kim came to recognize more and more how she herself played an active in viewing the external world negatively and keeping herself in a depressed state. She realized that if she were not provocative and looked for positive things in the outside world, they would appear there much more often than she expected. In this way, she could become an agent of positive change.

Gradually, Kim became aware of how unstructured and vulnerable her current life situation was. She realized how she was hurting herself by her continuing alcohol and drug use, and by ignoring opportunities to return to school or work.

Regarding the developing therapeutic symbiosis, Seinfeld stated,

“Kim’s vulnerable self became more connected to the internal holding object (the therapist as supporter of independent functioning and provider of love) through the transference, and she experienced severe separation anxiety. She faced the fact that her life was a mess and that she felt like a vulnerable child. She began to believe that I really was going to help her, that our relationship could affect the direction of the rest of her life.”

Seinfeld continued to explain that, at the same time as these positive feelings emerged, Kim feared that letting Seinfeld get too close to her would allow him to overpower and dominate her sense of self. She still feared trusting another person closely due to all the rejection from her past. So, she had to be very careful and gradual in the way she came to trust Seinfeld, lest he turn “bad”. Occasionally, she had dreams in which the “good” Seinfeld would turn into a psychotic madman like her father.

Gradually, Kim let herself get more and more attached to Seinfeld, and as this happened she began to feel self-empathy for the first time in her life. She remembered the alone, fearful child she had been and wanted to help herself.

Strengthening the Therapeutic Symbiosis

Kim bought a pet parrot that she would care for at home. She imagined herself as a good parent nurturing a good child most of the time. When the bird became difficult and squawky, she would briefly view herself as the bad mother and the bird as bad child. As her relationship with Seinfeld improved, she came to nurture her pet more and more and to be bothered less and less by its noisiness. As a projective container, it reinforced her positive internal self-and-object images via the fantasies of love she projected into it, supported by her relationship to Seinfeld.

Over the next year, Seinfeld described Kim’s progress as follows,

“As Kim became less depressed and angry , her vulnerability and strivings for autonomy emerged. Having decided that she must do something to change her life, she managed to earn a high school diploma. She then pursued college courses and part-time work… She brought to me her ambitions and interests for mirroring admiration. Her ambitions, which were originally grandiose, gradually became realistic. She informed her drug-addicted boyfriend that he had to stop using cocaine if he wanted to continue to see her. She saw him less as a rejecting object and more as a person with problems that interefered with his capacity for intimac. His family eventually arranged to have him go for detoxification. Kim remained in contact with him but also started to see other men.”

Seinfeld then described how Kim gradually focused more and more on her own goals and independence, and became less dependent and close to Seinfeld as she had been at the height of the therapeutic symbiotic phase. Thus she transferred into a more “resolution of symbiosis”-like phase, as described in Article #10.

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Comments on Seinfeld’s Case of Kim

In this case study, one can see how in the early phases of treatment, Kim was at first oblivious to Seinfeld as a potential helper, due to the extreme neglect and abuse she experienced as a child which left her with a structural deficit of positive internal self and object images. She literally could not recognize help and love when she saw them.

As she gradually became aware of Seinfeld as a potentially helpful therapist, her fear that he might reject her like her parents had done, as well as her general unfamiliarity with and distrust of genuinely kind people, caused her to distance herself from him as a potential good object. It required painstaking work to become aware of how she herself continually viewed others (and later Seinfeld) as “all-bad” while rejecting the good aspects of the outside world in order to overcome this phase.

Eventually, the therapeutic symbiosis took over, and Kim was able to trust Seinfeld and take in his love and support. At this point, she was no longer “borderline”, and began to feel well and stable much of the time. She resumed school and work, developed new positive relationships with other men, and gained a healthy capacity to view people like her mother and abusive boyfriend as troubled people rather than persecutory rejectors.

In reading this article, I learned how important it is to identify the subtle ways in which we distort others into “all-bad” and “all-good”, when we are borderline. We can apply these case examples our own lives, since we all distort external reality to a greater or lesser degree. Since they are often based unrealistic projections from past negative relationships, learning to “distrust” or question our initial negative perceptions can be a positive, corrective process. It allows us to realize how the world outside is much more positive than it sometimes appears when we are viewing things through the lenses of “bad objects.”

Seinfeld As An Author

Seinfeld is one of those authors I read about a certain topic and say, “Wow, this guy is brilliant! That really is how things are!” I remember being struck right away by his penetrating descriptions of borderline problems and what was necessary to transform them. The reader is again recommended to his book, “The Bad Object”, which is available used on Amazon. Its case studies of successfully treated borderlines are some of the best of any book I’ve read, especially the cases of “Kim” described here, along with similar-length successful cases of “Justine”, “Diane”, “William”, and “Peggy.”

To understand Seinfeld’s concepts, it may again be useful for the reader who is unfamiliar with the psychodynamic explanation of BPD to skim through the following articles:

Seinfeld adapted an object relations theory of trauma, building on theories developed by Ronald Fairbairn working with abused children in the early 20th century. Seinfeld understood how parental neglect and abuse became internalized by the (future borderline) child, and then was constantly replayed in their adult life, causing the borderline symptoms. He adapted the four phases that Harold Searles pioneered with schizophrenic patients, and modified them for use with less-disturbed borderlines. These phases – Out-of-Contact, Ambivalent Symbiosis, Therapeutic Symbiosis, and Individuation – involved “reparenting” the borderline individual so that they learned to love themselves and eventually became able to love other people.

It’s hard to summarize everything else from Seinfeld’s book on how to treat Borderline Personality Disorder (The Bad Object). So, as with the post on Gerald Adler, I will focus on a few key points.

#1: The Concepts of Structural Deficit and Bad-Object Conflict

One of Seinfeld’s foundations for understanding BPD was seeing a borderline individual as having both “a structural deficit of positive self-and-object images” and “bad object conflict.”

What the structural deficit means is that, compared to a healthier or “normal” individual, a borderline has not taken in sufficient positive experiences with the outside world to feel secure psychologically. This results in an inner emptiness or psychic void that makes it harder for the borderline to take in new positive experiences in the present, since they have trouble recognizing them as positive. This is the same concept as Adler’s notion of introjective insufficiency:

In healthier people, who have had much nurturing, love and security in childhood, the high number of past positive memories serve as “receptors” that help them recognize, seek out, and take in new positive experiences. By contrast, the borderline-to-be child usually receives very poor responses to their need for nurturance. Instead of internalizing a sense of love, security, and blessing, the future borderline child is left with an emptiness or longing for love which then becomes repressed. That is the structural deficit as described by Seinfeld and Adler – the quantitative insufficiency of internal positive memories based on a lack of past external positive experiences.

It is the structural deficit that results in the borderline’s being relatively unreceptive to new positive experience. For the adult borderline, positive experience – for example, being offered friendship, acceptance, and interest by other people – will seem unfamiliar, strange, alien, and even threatening when they are encountered. This is why, early on in the therapeutic process, Seinfeld found that severely borderline patients often didn’t know how to relate to him in a positive way. Rather, they experienced him in his helping role as, “an alien creature from another psychic planet.”

#2: Bad Object Conflict

As for “bad object conflict”, Seinfeld understood this to mean that not only is there a lack of positive memories, but there is a predominance of powerful negative memories (or images of oneself and other people) in the borderline’s mind. These scary, traumatic negative memories don’t just sit there – they act to reject the internalization of new positive memories. They are like metaphorical demons or monsters that scare the patient away from trusting others.

The child who becomes borderline internalizes many memories of being unloved, rejected, and even hated by inadequate parents. These memories collectively form the unconscious “internal bad object” or “rejecting object.” Despite its painful nature, relating to a rejecting other as an adult often feels safer and more familiar than trusting someone new who might prove disappointing. Also, the borderline tends to feel a perverse loyalty toward the people who abused him in the past, and to feel he is “bad” and therefore unworthy of help from good people.

For both these reasons – fear of being vulnerable toward good people, and loyalty toward the bad people from the past – the borderline individual tends to reject potential help and remains attached to the image of themselves as a worthless, undeserving, bad person. This can be acted out in many ways – via remaining alone and isolated, via abusive or neglectful relationships with present-day partners, via staying attached to the original abusive parents in the present day, via self-injurious acting-out behaviors, and so on.

Therefore, Seinfeld described how the borderline acts in subtle and overt ways to actively maintain an internal negative view of themselves and others. I would call this, “Perpetuating the past in the present.” The bad-object conflict thereby works in a vicious cycle to maintain the “structural deficit” because as long as the activities focused around bad perceptions of oneself and others predominate, quantitatively speaking, then new positive experiences are not being taken in in sufficient amounts to “tip the balance” and effect lasting psychic change.

Seinfeld likened the negative and positive relationships of a borderline patient (as long as they remain borderline) to a mathematical equation. In his formula, negative relationships to external others are activated more frequently than positive relationships, maintaining the attachment to the internal bad object and preventing the internalization of a good set of self-and-object images strong enough to displace the bad object.

According to Seinfeld, unawareness of the good object (“object” meaning person or people) tends to occur more in the out-of-contact phase, and active rejection tends to occur more in the ambivalently symbiotic phase, as described in post #10 on the Four Phases. Active rejection is necessary in the ambivalent symbiotic phase, because the good-object images are strong enough in that phase to pose a threat to the internalized bad object, which the patient unconsciously fears losing (since it is what he is familiar with).

#3: The Exciting Object

Another key concept from Seinfeld’s writing is the nonhuman exciting object. The exciting object is any addictive, stimulating, non-human object that serves to fill the void created by the lack of the good object. Food, drugs, sex, alcohol, medications, excessive use of TV or internet, and other nonhuman “things” can provide an addictive fix to compensate for the lack of love that a borderline feels.

The exciting object is part of Seinfeld’s mathematical equation of how BPD works. Because of the structural deficit and the bad object conflict, the all-negative split self and object units are mostly dominant in the borderline’s mind. These all-negative images reject the taking in of new positive experience which could be soothing, and therefore the borderline feels mostly empty, unhappy, and unstable emotionally.

To try to assuage these bad feelings, the borderline turns to nonhuman exciting objects as described above. These exciting objects plug the “hole” or emptiness created by the lack of truly satisfying positive relationships to good people in the outside world. However, exciting objects can only do so temporarily, since they are not truly satisfying long-term. Once their effect wears off, frustration will set in, and the borderline will usually return to involvement with the bad self and object images. This will then lead to more psychic pain around bad objects, resulting in the need for more exciting objects to assuage it, and so on.

The main focus of Seinfeld’s book was not on the negative aspects of how a borderline functions, but on how to heal them. Seinfeld believed this could be done by interrupting the constant oscillation between rejecting and exciting objects via the internalization of a new good object relationship.

In normal language, the borderline needs to overcome their fear of trust and dependence, allowing themselves to develop a satisfying, loving relationship with the therapist. Seinfeld emphasized that successful therapy must move beyond a detached, professional relationship, and should explicitly involve love and closeness between patient and therapist. This does not mean that the pair are friends outside the sessions; rather, it means that a parental-like relationship of vulnerability, tenderness, and support is nurtured within the frame of the sessions.

This is the phase of therapeutic symbiosis. Seinfeld described how, “In this phase, there is a full reemergence of the vulnerable, regressive true self, in the care and protection of the idealized holding-therapist… At first, the patient’s vulnerable self is increasingly related to the therapist as holding object. The Internal positive self and object representation unit is increasingly dominant over the negative self and object representation unit, as long as the external therapist is highly available to reinforce the strengthening of the positive unit… As one patient said, “So long as everything is all right between you and me, I feel that all is well with the world. The good internal object serves to neutralize the bad, persecutory, rejecting object….

“In the later part of therapeutic symbiosis, the patient internalizes and identifies with the therapist to the point at which he is no longer so dependent upon the external therapist… The patient can now increasingly comfort, soothe, and mirror himself, regulating his own affect, mood, and self-esteem. In unconscious fantasy, he is now the comforter, sympathizer, and holder, as well as the comforted, empathized with, and held… All goodness is taken into the self; all badness is projected into the external object world…. In this way, the patient can establish a psychic foundation (of primarily positive self and object images) to eventually integrate the good and bad self and object units into whole, or ambivalently experienced, self and object images.” (pages 73-74)

Seinfeld’s Model of BPD – The Inversion of the Normative Developmental Psychic Process

Seinfeld continues, “The healthy child tries to take in or internalize the good object and reject or externalize the bad object. In the model I’m developing, the borderline patient manifests an inversion of the normative developmental process. Instead of taking in the positive object relations unit and rejecting the negative object relations unit, he takes in the negative object relations unit and rejects the positive object relations unit. In Fairbairn’s terms, he is attached to the internal bad object. The out-of-contact phase and ambivalent symbiosis are manifestations of the pathological inverted symbiosis in terms of the attachment to the bad object and rejection of the good object. Symbiosis becomes therapeutic when the patient adopts the normative but primitive developmental position of taking in all that is good and rejecting all that is bad. In this way, the patient can establish a psychic foundation to eventually integrate the good and bad object relations unit.” (page 75)

To me, this is a beautifully clear model of what causes BPD – bad relationships are taken in during development and reenacted continuously during adulthood, whereas good relationships are not taken in and are rejected later on. Successful recovery from BPD involves an reversal of this process.

Through the phase of therapeutic symbiosis, the patient can gradually gain confidence and make progress in three main areas in their outside life: 1) Leaving behind negative relationships (for example, to abusive partners, friends, or parents), 2) Developing new positive friendships and relationships to replace the bad ones, and 3) Developing enhanced autonomous functioning, work and interests.

In this way, the formerly borderline patient reverses the mathematical equation that had predominated when they were “borderline.” Instead of remaining attached to the all-negative images of themselves and others, the patient engages in new relationships and activities that are good, encouraging and self-supporting. In this way they take in a quantitative predominance of positive self-and-object images, and “spit out” the bad self and object images.

How To Interrupt the Rejecting-Exciting Object Cycle – Insight

The reader is probably interested as to how a borderline may start to break out of the negative-exciting object attachments. What Seinfeld worked on in therapy (and what one can work on with oneself) is developing the insight into how one sabotages oneself, which allows one to start making more constructive and adaptive choices instead.

Attachments to bad objects from the past are like schemas or relationship-templates that one replays over and over in the present “perpetuating the past in the present”), even though one doesn’t have to keep doing so. A person needs to identify how they are replaying bad relationships in the present, and treating themselves in the way that their parents did, to begin realizing how their behavior could change. As they become aware of the structural deficit (of positive self and other representations, resulting in unreceptivity toward good experience), and of the bad object conflict (which actively rejects and causes a person to fear good relationships), the borderline can start to actively seek out better experiences.

A great way to illustrate how this process works is via a case example. Hopefully, in the case of Kim above, the reader should be able to identify the structural deficit, bad object-conflict, use of exciting objects, and the ways in which Seinfeld interrupted these activities and nurtured insight in the patient, to encourage internalization of the therapist as a good object.

Recovery as a Mythic Journey

Lastly, I loved Seinfeld’s view of the therapy process as a mythic or epic journey. Seinfeld states (page ix), “This volume shows how to help the patient overcome what has been decribed as the most serious obstacle to psychotherapy: the negative therapeutic reaction. It is the bad object that is predominantly responsible for this reaction. The patient and therapist enduring the travails of the therapeutic journey often resemble Odysseus and his crew forced to outwit the demons, sirens, witches, and Cyclops threatening to thwart the long voyage. In fact, those mythological demons personify the manifold masks of the bad object often described as exciting (but not satisfying), enticing, bewitching, addicting, engulfing, rejecting , punishing, and persecuting…

“The bad object is comprised of the actual negative attributes of the parental figures – often a composite of both mother and father along with later figures resembling them – and the child’s fantasies and distortions about these figures. In this regard, the unsatisfactory experiences with the parental figures give rise to frustration and anger, which color the child’s perception of the object… The designation “bad” regarding the other person does not refer to a moral valuation but rather to the child’s subjective unsatisfactory experience with it… Therapeutic progress threatens the patient and therapist with the terrible wrath of the bad object. The patient is conflicted between his loyalty and fear of the bad object and the longing to enter into a good object relationship that will promote separation from the bad object… Fairbairn believed that the term “salvation” was a more apt designation than that of “cure” for the patient’s subjective experience of his need to be rescued from the bad object.” (preface page x)

This article is getting long enough already! I hope the reader, whether having borderline traits themselves, or wanting to help or understand someone with BPD, has found some interesting insights in Seinfeld’s approach to treating Borderline Personality Disorder.

Lastly, here is an interview and memoriam for Jeffrey Seinfeld, who sadly passed away a few years ago.

If you are struggling with BPD yourself or are trying to help a borderline individual, I would be happy to listen to your story and provide feedback if possible. Feel free to provide constructive criticism of this site also.

This article is the opinion of a non-professional layperson, and should not be taken as medical advice or as the view of a therapist who is professionally qualified to treat Borderline Personality Disorder or any other mental health condition. Readers should consult with a qualified mental health professional before undertaking any treatment.

Thus far on this blog, I have described my recovery from borderline symptoms and outlined a psychodynamic understanding of Borderline Personality Disorder.

Today I would like to take on some of the highly prevalent myths about BPD. These ideas circulate across the internet on forums, blogs, and webpages about BPD. To me, they are unreasonably pessimistic, scientifically baseless, and unhelpful.

Here are five myths that people newly diagnosed with BPD are often told:

Myth #1: Borderlines cannot become lastingly free from borderline symptoms (i.e. BPD can only be ameliorated, not removed).
Myth #2: Effective treatments that “cure” BPD have not yet been developed.
Myth #3: BPD is caused by genes and biology.
Myth #4: Medication and therapy are equally effective treatments for BPD.
Myth #5: BPD is a valid diagnosis and a real medical condition.

If you are upset by any of these ideas, you don’t have to continue reading – after all, I can’t force people to give up their view of BPD as incurable, genetically-based, and a valid scientific diagnosis. But if you are open to the possibility that rejecting these notions can be encouraging and useful, read on.

Myth #1: Borderlines cannot become lastingly free from borderline symptoms (i.e. BPD can only be ameliorated, not removed).

On some BPD blogs, one reads that BPD is a “life sentence”, that “there is no cure for BPD”, that “BPD symptoms can only be managed”, and so on. My reaction to these statements is pity. It is tragic that people who are already facing severe life challenges have their problems compounded by such unwarranted pessimism. It creates a vicious cycle, where people who are already struggling with real emotional problems are further discouraged by hearing – falsely – that they are unlikely to recover. This then exacerbates their real problems, leading to further discouragement, and so on.

Can I prove on this blog that BPD can be fully recovered from, as one can prove that water boils at 212 Farenheit? No. But what I do have is my own experience, plus a large amount of research on BPD gleaned from former BPD sufferers and therapists.

For the six year period from about 2003-2008, I suffered with all of the nine borderline symptoms in the DSM. It was absolutely hellish – most days were a psychological war, filled with constant anxiety, bleak depression, hopelessness about the future, suicidal thinking, feeling horribly alone, being unable to relate positively to anybody, and so on. Because I’ve been there, I understand where other blogs about BPD being so difficult are coming from. I describe my difficult experience more in post #3, “The Tragic Borderline Experience.”

But as of 2014, I have been developing increasingly good relationships and functioning better and better for the last 5-6 years. I don’t have any of my former borderline symptoms, nor do I fear they will recur. Most of the time, I’ve felt vigorous, alive, capable, motivated, and real. A small minority of the time, I feel worried and down, but not more than most people and not without real cause. In light of my past history, I feel that I have triumphed. I describe how this progress occurred in post #2, “How Did I Recover from BPD?”

This personal experience convinces me that BPD can be recovered from in a deep, lasting way. We only truly know what we directly experience, and that is my “proof”. My experience indicates that BPD can not only be ameliorated and managed – it can be fully dissolved, removed, and triumphed over.

Perhaps somebody reading this is saying, “Edward, how do we know you’re telling the truth? This whole blog could be a fantasy.” While that is untrue, let’s indulge that fantasy for a moment. 🙂 Taking my experience out of the equation, what other evidence says that borderlines have recovered to live good lives as non-borderlines?

Secondly, there are dozens of books with hundreds of case studies of borderlines who recovered. For example:

James Masterson – Psychotherapy of the Borderline Adult
Jeffrey Seinfeld – The Bad Object
Helen Albanese – The Difficult Borderline Patient: Not So Difficult To Treat
Peter Giovacchini – Borderline Patients, the Psychosomatic Focus and the Therapeutic Process
Bryce Boyer – Psychoanalytic Treatment of Schizophrenic and Characterological Disorders
Vamik Volkan – Six Steps in the Treatment of Borderline Personality Organization
William Meissner – Treatment of Patients in the Borderline Spectrum
Gerald Adler – Borderline Psychopathology and Its Treatment
Donald Roberts – Another Chance to Be Real: The Treatment of Borderline Personality Disorder
Harold Searles – My Work with Borderline Patients

These are some of the psychodynamic books that are my area of interest (if one added in CBT and DBT, you could come up with a much bigger list of books that are optimistic about BPD). These ten books alone contain about 40-50 case studies of borderline patients who recovered fully and/or made great improvements to become diagnostically non-borderline. I don’t recommend reading these books, because it is more useful to connect with real people. However, they show that many therapists have worked successfully long-term to cure patients with Borderline Personality Disorder. I doubt that all of these authors are colluding to lie about borderlines getting better 🙂

So, an increasing number of direct-experience accounts and professional-therapist accounts of BPD recovery are now available to provide hope. The question should no longer be whether borderlines can become non-borderline, but how better to provide them the resources to enable deep and lasting recovery.

Myth #2 : Effective Treatments that “Cure” BPD Have Not Yet Been Developed

As a medical word, “cure” is probably not the right word for an emotional condition like BPD. Perhaps one would do better to say “deep recovery”, “living the life you want”, “finding fulfillment and meaning”, “being free from constant emotional suffering”, etc. Whatever terms are used, there are treatments and support systems that make these things a real possibility for sufferers of BPD.

Since it is very similar to the first myth, I will not write about this idea at length. However, there are several effective treatments that can lead a person to no longer meet the criteria for BPD. My favorite approach is psychodynamic-psychoanalytic psychotherapy, of which all the books listed above under Myth #1 are examples. Reading the case studies in these books leaves little doubt that borderlines can become free from their symptoms. That’s not to say it’s easy or immediate; it takes years of work. But it’s possible for anyone.

Other effective approaches include DBT (Marsha Linehan’s approach), Mentalization Based Therapy (Peter Fonagy), and Transference Focused Psychotherapy (Otto Kernberg). I am not as familiar with these approaches, so cannot comment at length. However, many people with borderline issues have reported that they are very helpful, as can be seen at forums like http://www.PsychCentral.com . Debbie Corso’s blog gives a lot of information about DBT and how she used it to recover. I recommend the reader to check out her story, linked above.

Although some aspects of this report are suspect (since it is based on the medical-model version of BPD, and implies that it is partly a biologically-caused disorder, which I disagree with), it is encouraging in that it reports statistics such as:
– Over a 10-year period, over 90% of patients eventually experience a remission of BPD as defined by not meeting enough of the DSM criteria for the disorder.
– 78% of (formerly) borderline patients attain broadly-defined good psychosocial functioning over a 10-year period (defined as at least one meaningfully close relationship with a partner or friend, and good work/vocational functioning).

These numbers are based on about 300 borderline patients who were followed for 10 years after initial intake into a hospital in the Northeastern US. It’s not possible to generalize to any one person based on group statistics, but they show that improvement and remission from BPD is very possible. Many people diagnosed with BPD are still being indoctrinated with the idea that it is an incurable, life-long illness. It’s time to begin changing that attitude.

Myth #3: “BPD Is Primarily Caused by Genes and Biology”

This is a statement that I read now and start laughing. Often promoted by drug companies, hospitals and universities (funded by Big Pharma), or establishments psychiatrists, websites touting this viewpoint say, “We now know that BPD is caused by both genetic and environmental factors!” or, “A person with BPD has a broken brain!” or, “BPD has now been found to be 68.72% hereditary!”

To go back to one of my earlier articles, I’d ask the reader to consider the following:

BPD is based on 9 subjectively assessed symptoms. Jack could have symptoms 1 through 5 only. Jane could have symptoms 5 through 9 only. Both would be “borderline”, even though they shared only one symptom in common and have four unique symptoms each. For example, they could both have self-injurious acting out (e.g. being promiscuous or abusing a substance), but be completely different in their other symptoms.

The extreme biological determinists would say that Jack and Jane have the same “disease,” and that is it is genetic and biological, caused by misfiring neurons. This makes no sense. Patterns of complex human emotional problems that (in some cases) barely overlap cannot be reduced to a biologically-caused disease.

In my view, the motivation behind labelling BPD as a biologically-caused disorder is profit. Pharmaceutical companies want to sell more drugs, and to do so, they need to promote the myth that emotional problems originate in brain biochemistry. This is discussed further here:

As for BPD being hereditary, that is equally ridiculous. Firstly, the notion that a genetic percentage-contributor for the condition can be quantified is simply not true, given the complex way in which genes and environment interact. I recommend the reader to Evelyn Fox Keller’s outstanding book, “The Mirage of a Space Between Nature and Nurture”, for an explanation of this concept.

While constitutional vulnerability to stress may be a factor in who develops so-called “borderline” symptoms, that does not mean BPD runs in families due to genetic factors (although, it may certainly run in families due to generationally-transmitted abuse and neglect). In an earlier article, the way in which gene studies misrepresent BPD and other mental health conditions as biological diseases was discussed:

Given that medications only treat the anxiety and depression associated with BPD, rather than BPD itself, my position is that medications can at best be palliative. Palliative means they reduce symptoms to a limited degree, without treating the root cause of someone’s problems. At worst, medications can cause horrible side effects, waste money, and promote the fantasy that pills will solve long-standing personality problems.

I have never heard of a borderline who was cured by medication alone. But as discussed above, there is convincing evidence, both from first-person accounts of recovered borderlines, and from third-person accounts of therapists working with borderlines, that full lasting recovery from BPD can be achieved via psychotherapy, self-help, and human support in general. Therefore, psychotherapy and human support are the treatments of choice for BPD.

It should be noted that medications are not all bad. In my early years of coping with extreme rage and hopelessness, I used psychiatric medication for a limited time. It stopped me from being overwhelmed by anxiety. However, after entering therapy and stabilizing, I gradually titrated off the medication. In the big picture, medication was a very limited tool.

Myth #5: BPD is a valid diagnosis and a real medical condition.

It is time to reveal my true colors. I do not believe that BPD is a real disorder, although I believe all its symptoms are real and painful. Let me explain.

Saying that BPD exists is like saying that a certain group of stars in the sky are the “Big Dipper” constellation. There is nothing in nature that makes a constellation exist, only humans’ illusory projection of order into the stars’ positioning. In other words, a constellation itself is not a real external entity – it’s just an idea in people’s minds projected onto that external entity. It is a reification or simulacrum.

Likewise, BPD is an artificial construct. Like a constellation based on stars, BPD is based upon an artificial grouping of human behaviors, although there is nothing innately in those behaviors that makes it valid. Unlike constellations, BPD is even less reliable, because at least constellations are based on artificial groupings of clear physical entities. BPD, on the other hand, is based on subjectively assessed psychological-emotional symptoms which must reach a certain threshold intensity for inclusion. Why those nine symptoms were chosen for BPD (and not dozens of other possible symptoms), why it should be nine symptoms and not more or less, and when exactly each symptom is intense or different enough from “normality” for inclusion, are all mysterious, hard-to-answer questions.

More insidiously, these questions lay bare the fact that BPD is a nonscientific figment of psychiatrists’ imagination. I have no hesitation in saying this, despite having had all nine “borderline” symptoms myself. BPD as a medical condition is a fraud. It is richly ironic that the term “borderline” appears so often on this site, when I do not even believe in its validity.

However, as I noted in article #8 on the BPD diagnosis, BPD does have its uses. It does have some generally understood, if imprecise, connotations. One must admit that BPD means something to some people, although exactly what is not always clear. Because people insist on speaking about BPD as a valid medical diagnosis, I have found a way to think about it usefully. I usually translate “borderline” to mean that a person is struggling with some uncertain degree of severe emotional problems, often based on early neglect and/or abuse, and usually involving splitting in which negative perceptions of self and other are stronger than the positive self-and-other units. For me, this is more meaningful than the trite and superficial DSM diagnosis. This self-and-object theory is described here:

When I read on a blog that someone “has” BPD; my first thought is that this doesn’t tell me much about them. I am more interested in hearing about their personal history, what they are anxious about, their hopes for the future, what resources they are using to improve, etc. Those things are real. The main positive aspect of the BPD label is that it allows people to find effective help for the range of problems that are imperfectly described by that label.

I would like to share here the viewpoint of the British Psychological Society (Great Britain’s counterpart to the American Psychological Association) on the validity of personality disorders and other mental health diagnostic categories:

“One way of examining the validity of mental health diagnostic categories involves using statistical techniques to investigate whether people’s experiences actually do cluster together in the way predicted by the diagnostic approach. The results of this research have not generally supported the validity of distinct diagnostic categories. For example, the correlation amongst symptoms for specific mental disorders has been found to be no greater than if the symptoms had been put together randomly. Similarly, cluster analysis – a statistical technique for assigning people to groups according to particular characteristics – has shown that the majority of psychiatric patients would not be assigned to any recognizable group. Statistical techniques have also highlighted the extensive overlap between those diagnosed with one disorder and those diagnosed with another.”

(from the newsletter of the British Psychological Society (BPS), 2000, pg. 17. I have altered a few words to make the meaning clearer as applied to personality disorders, rather than psychoses, which the original paragraph also discussed. However, the essential meaning of the passage is unchanged.)

The BPS viewpoint implies that there are no clear boundaries between, and thus little validity or reliability within, each of the mental disorders of the DSM, including Borderline Personality Disorder.

Interestingly, if ones accepts that Myth #5 is indeed a myth (in other words, that BPD is not a valid medical condition), then it becomes necessary to reevaluate myths # 1 through 4. Here they are again:

If the placeholder “BPD” is actually an unreliable, fictional diagnosis, then many of these ideas cease to have meaning. One cannot become free from a condition that is not diagnostically valid; one cannot be cured of something that cannot be reliably identified, genes cannot cause a fictitious disorder, and medication and therapy cannot be compared for the treatment of a speculative phenomenon.

This is how I now think about BPD. Such an approach might seem invalidating. However, I empathize with people’s experience of being borderline as an identity, as I thought of myself that way for many years. What I am saying doesn’t mean that people’s suffering or experience is not real, only that the medicalization of emotional suffering, crystallized in BPD as a diagnosis, is suspect.

Paradoxically, I find rejecting the notion of BPD as a valid diagnosis to be encouraging and human. All nine symptoms listed under the BPD diagnosis are real and occur to different degrees in different people. But, I don’t believe someone suddenly “has” BPD when they have five out of nine of them.

Rather, I try to see human problems, including the nine so-called BPD symptoms, as existing on a complex continuum. On this spectrum, everyone’s problems are unique and cannot be compartmentalized into “diagnoses”. Such an approach is more human and respectful of individual differences. It’s not easy to think that way, since we are accustomed to think in categories and divisions. But I never liked how psychiatry labels many severely troubled people as “borderlines” when really, everyone’s problems are their own.

Some of these ideas might be controversial, especially this last myth. I don’t expect everyone to agree. If you have your own opinion, feel free to share it in the comments below. There’s a need for increasing dialogue, both about what can help people who are diagnosed with BPD improve, and also about the worth of the BPD diagnosis. Although it may be controversial, such dialogue may be interesting and useful, and can only have a positive effect for those diagnosed with BPD in the long-term.

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I welcome any correspondance at bpdtransformation@gmail.com

If you are struggling with BPD yourself or are trying to help a borderline individual, I would be happy to listen to your story and provide feedback if possible. Feel free to provide constructive criticism of this site also.

This article is the opinion of a non-professional layperson, and should not be taken as medical advice or as the view of a therapist who is professionally qualified to treat Borderline Personality Disorder or any other mental health condition. Readers should consult with a qualified mental health professional before undertaking any treatment.

Several years ago, when I feared that full recovery from BPD was impossible, my therapist recommended me to read Gerald Adler’s book Borderline Psychopathology and Its Treatment.

Now in his mid-80’s, Adler had earned a reputation as one of the best psychodynamic theorists writing about Borderline Personality Disorder. In the early 1990s, Adler visited the Washington School of Psychiatry to give a talk which my old therapist attended.

What impressed my therapist most was not Adler’s knowledge or clinical skill, but his compassion and goodwill. Out of all the speakers she remembers, only Adler stayed two extra hours to answer questions from junior therapists.

I have met Adler in Boston and spoken to him via phone and Skype five other times. He engaged my fears about BPD compassionately yet forcefully. He had a wonderful quality of being active in directly addressing what was bothering you, but in a manner that felt supportive not intrusive. He reached me even though I was regressed and depressed at the time.

In this article, I’ll discuss some of the key theoretical views of Gerald Adler on Borderline Personality Disorder. Get ready to learn from a master!

The Primacy of Introjective Insufficiency

First, I would like to quote some of Adler’s views on the importance of borderlines’ lack of positive relational experience.

Several decades ago, psychodynamic writers debated about whether inability to tolerate ambivalence – i.e. to see people and oneself as good and bad simultaneously – was the primary problem for borderlines, or whether the main issue was an earlier failure of nurturing which led secondarily to the inability to tolerate ambivalence. Here is Adler’s position (from Borderline Psychopathology and Its Treatment, pages 10-12):

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“In the ambivalence theory account of borderline functioning, introjective insufficiency results from an inability to tolerate ambivalence toward the whole object. But my own clinical experience suggests the utility of a different theoretical approach.

If the primary issue for borderline patients were the need to keep apart introjects of contrasting affective coloration, then there must already have been substantial solid development of positive introjects around which the self is organized. While ambivalence toward the whole object may then lead to a lack of self-cohesiveness, it would not issue in the felt threat of annihilation.

Only a theory that views insufficiency as primary – and not merely a secondary or reactive expression of ambivalence – can fully account for the borderline patient’s “annihilation panic” in regression. In other words, only a primary inner emptiness, based on a relative absence of positive introjects around which the self is organized , can adequately explain the borderline patient’s vulnerability to feeling that his very self is at risk.”

Explanation of Adler’s View on Introjective Insufficiency

This might seem confusing. Very simply, Adler is saying that the primary problem for borderlines is not their all-good all-bad splitting – which is a symptom – but rather their lack of sufficient positive introjects, which is the underlying cause of their psychopathology.

By “introject”, Adler refers to an internalized mental representation of another person and the way they make us feel. “Positive introjects” are comforting, supportive representations of other people, for example those of caring parents. A healthy child develops solid, reliable positive introjects to soothe itself based on mostly good experiences with its parents. Such a child can use “evocative memory” to comfort itself by remembering how good relationships feel even when the external person is not physically present.

“Negative introjects” are persecutory, hurtful memories, for example those with neglectful and abusive parents. Negative introjects predominate in the minds of future borderline children. A relative deficit of positive introjects, whch are outnumbered by negative persecutory introjects, causes borderline psychopathology in Adler’s model

“Introjective insufficiency” means a lack of sufficient positive introjects to comfort oneself. It is this introjective insufficiency that results in the feelings of emptiness, panic, and fear that borderlines often experience. In stressful situations, the lack of positive introjects leads borderlines to feel that their very psychological being is under threat.

That is what Adler means when he discusses “annihilation panic”. In a healthier person, stress would be challenging – i.e. it would affect their “self-cohesiveness” and make them feel “not like themselves” – but it would not make them feel that their psychological being was threatened.

However, with borderline individuals who have had little positive nurturance growing up, and whose positive introjects and self-comforting are therefore tenuous, emotional stress leads to the feeling that they may be destroyed psychologically. In Adler’s view, the strength and frequency of this phenomenon supports the idea that a lack of positive introjects is primary for borderlines, and that inability to tolerate ambivalence is secondarily based on this deficit.

As humans we need positive relationships, and positive introjects derived from them, for our psychological survival and well-being. Positive introjects serve the mind the same way oxygen serves the body. When they are weak, we feel existentially threatened, like a mountain climber running short of oxygen.

Adler’ view of BPD is a “deficit” model – he focuses on what is missing in a person’s psychological development, and on what is needed to remedy the deficit. Other therapists focus more on “conflict”, i.e. what conflicts associated with “bad” relationships block the borderline’s psychological development. These approaches are complementary and could be considered sides of the same coin.

Adler’s View on the Cause of Borderline Personality Disorder

(from pages 20-23)

“The fundamental psychopathology of the borderline personality is in the nature of developmental failure: Adult borderline patients have not achieved solid evocative memory in the area of object relations and are prone to regress in this area to recognition memory or earlier stages when faced with certain stresses. The result is relative failure to develop internal resources for holding-soothing security adequate to meet the needs of adult life.

To repeat, the formation of holding introjects – of both past and present figures – is quantitatively inadequate, and those that have formed are unstable, being subject to regressive loss of function. The developmental failure appears to result from mothering that is not good-enough during the phases of separation-individuation. Although the young person is ready for the neuro-psychological development of memory needed to form holding-soothing representations and introjects, the environment does not facilitate it.”

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Discussion of Adler’s View on the Cause of BPD

Adler’s point is that parental support is usually lacking in the histories of children who become borderline, and that lack of support leaves them unable to comfort themselves as adults. According to Adler, future borderline children are psychologically capable of developing self-soothing capacity, but they experience too much neglect and/or abuse to allow for it. Adler noted that in virtually every case of BPD he treated (comprising dozens of borderline patients over a 40-50 year career), the borderline patient reported significant neglect or abuse in their childhood.

I believe that genetic strength or weakness is a factor too. However, I place less much value on this aspect BPD’s etiology than genetic researchers, most of whom, unlike Adler, have never worked with borderlines in depth. In my view, the dynamic interaction of the environment with the individual generates borderline symptoms. The prevalence of neglect and abuse reported by borderlines underscores the crucial importance of human relationships in causing borderline symptoms. This issue is elaborated on here:

Adler also discusses how positive introjects are “quantitatively inadequate” in BPD. This is a critical concept. Borderlines simply do not have enough positive experience with the outside world to be able to comfort themselves or to tolerate ambivalence. The main problem that causes all other borderlines symptoms is borderlines’ relative lack of positive experience with other people (and the associated lack of positive memories/introjects). This concept of the relative balance of positive and negative self-and-object units is discussed further here:

In an earlier article, I described Searles and Seinfeld’s four phases of treatment for BPD. Adler has a related model comprising three phrases. Here I’ll quote the way Adler describes these phases at length. I have slightly paraphrased some areas to make them more accessible, while keeping the meaning intact.

Phase 1: Phase I: Inadequate and Unstable Holding Introjects

Here is Adler’s description of Phase 1, from Borderline Psychopathology and Its Treatment, pages 49-53. It has been shortened and sometimes paraphrased for clarification:

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“The primary aim of treatment in the first phase is to establish and maintain a dyadic therapeutic relationship in which the therapist can be steadily used over time by the patient as a holding selfobject. This situation makes it possible for the patient to develop insight into the nature and basis of his aloneness, and to acquire a solid evocative memory of the therapist as sustainable holder, which in turn serves as a substrate out of which can be formed adequate holding introjects. That is, developmental processes that were at one time arrested are now set in motion to correct the original failure.

This process would simply require a period of time for its occurrence were it not for certain psychodynamic obstacles that block it in therapy just as they block it in life… The inevitability of rage is one such corollary that interferes with the process of forming holding introjects. This rage has three sources…
1) Holding is never enough to meet the felt need to assuage aloneness, which enrages the patient. The patient expects to lose the therapist through the therapist’s responding to his rage by turning from “good” to “bad”.
2) The holding selfobject that does not meet the need is not only the target for direct rage but is also distorted by means of projection of hostile introjects… The inevitable result of this projection is the loss of the good holding object.
3) The object that is so endowed with holding sustenance is deeply envied by the needy borderline patient. This envy necessarily involves hateful destructive impulses.

Any of these sources of rage can lead to transient loss of holding introjects. At such times the patient is subject to the terrifying feeling that the therapist has ceased to exist.

There is yet one more impediment to the use of the therapist as a holding selfobject. It is a primitive, guilt-related experience that involves the belief by the patient that he is undeserving of the therapist’s help because of his evilness. In extreme situations this guilt can lead to suicide attempts.

Acquiring insight into and working through these challenges are necessary in order for the borderline patient to develop a stable evocative memory for the therapist as holding sustainer. Each of these impediments must be worked through in the standard ways as it manifests in transference, through use of the therapeutic maneuvers of clarification, confrontation, and interpretation. The amount of support required may considerably exceed that involved in most psychotherapies.

The outcome of the work is this: The patient learns that the therapist is an enduring and reliable holding selfobject, that the therapist is indestructible as a “good object”, that holding closeness poses no dangers, and that the patient himself is not evil. Hope is aroused that the relationship and the therapeutic work, involving understanding of object and selfobject transferences plus genetic reconstructions, will open the way for psychological development and relief.

The healing of longstanding splitting of the type Kernberg describes must await the formation of stable holding introjects. Efforts to bring together the positive and negative sides of the split can be therapeutic only after development of more stable holding introjects along with correction of distorting projections that have acted to intensify the negative side of the split.

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Discussion of Phase I

Some of the technical terminology might be confusing. By “holding” Adler means the comforting psychological aspect of a relationship, not literal physical holding. “Holding” is a primary psychological element of any deep friendship, love relationship, or therapeutic alliance.

The “selfobject” is a term referring to the way the therapist is experienced as a comforting person or “good parent” by the patient. It describes how the patient experiences the therapist as serving their emotional needs, without fully realizing that the therapist is a separate person psychologically. That is why there is no space between “self” and “object” as written. It was invented by Heinz Kohut who wrote about its value to narcissistic patients.

Adler’s main points are that the borderline needs a new, positive relationship to grow psychologically, and that emotional resistances to forming that relationship must be confronted and removed. Borderline individuals reading this can probably agree that rage, fear, and guilt create obstacles to forming a positive relationship in therapy.

In the book, Adler details how the resistances to forming a positive new relationship to the therapist – i.e. rage about the imperfections of the therapist, envy of the therapist, fear of closeness, guilt – must be directly interpreted and confronted to allow the patient to internalize the therapist as a positive new object. This is a lengthy, gradual process taking many months and sometimes years.

Adler’s last paragraph is important – about how splitting cannot be resolved until a stronger positive relationship between patient and therapist exists (with correspondingly stronger positive introjects in the patient). In my early attempts at recovery, I worked on seeing things in a less black and white way. I had little to no success.

I eventually gave up and focused on building a positive relationship to my therapist, and also to my family and new friends. Eventually, the process of resolving splitting happened naturally a few years later, once more positive relationships were in place. My experience confirmed Adler’s view that correction of splitting must await the development of more stable positive relationships/introjects.

Adler also notes the importance of correcting “distorting projections that have acted to intensify the negative side of the split”. I learned much from this insight. What it means is that overly negative, distorted beliefs about the external world serve to prevent borderlines from seeing themselves and others ambivalently. It is necessary to “extract” these negative beliefs and correct them into views that are more realistic and balanced. This sets the stage for ambivalence rather than splitting.

In my case, I had various distorted views of the external world, for example:
1) That everyone thought I was ugly.
2) That women would not want to date me if they knew of my sexual inexperience.
3) That most therapists agreed that BPD was untreatable.
4) That therapists couldn’t be trusted and only cared about money.

I thought and acted as if people actually believed these things. It was necessary to correct these beliefs in order to view other people and myself realistically.

I liken the process of confronting such “distorted projections” to that of cleaning an infected wound. As long as the pus remains inside the wound, it festers, hurts, and may get worse. Draining the infected area is painful, but ultimately brings relief and allows for healing. Likewise, confronting painful, guilt-laden beliefs is uncomfortable, but ultimately freeing, promoting the development of a more realistic view of the world.

Lastly, Adler’s entire Phase 1 can be compared to Phases 1 and 2 (Out-of-Contact and Ambivalent phases) plus the early part of phase 3 (Therapeutic Symbiosis) in Jeffrey Seinfeld’s conception of BPD treatment, described here:

Next, Adler describes the phase of treatment after the borderline has developed a stable positive relationship to the therapist. From pages 58-60:

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“In general the holding introjects established in phase I are considerably unrealistic; they are idealized in a childlike fashion. Were treatment to stop here, the situation would be quite unstable, for two reasons. First, the unrealistic idealization of the holding introjects (based on the therapist), along with the projections of them onto persons (in the patient’s external life) who serve as holding selfobjects, would eventually be confronted by reality and would inevitably break down.

Second, at this point the patient is still heavily dependent on a continuing relationship with holding self-objects (including the therapist), as well as holding introjects, for an ongoing sense of security; this is not a viable setup for adult life, in which selfobjects cannot realistically be consistently available, and must over the years be lost in considerable number.

The therapeutic work in phase II parallels that described by Kohut in treating narcissistic personalities. Kohut describes the therapeutic process as “optimal disillusionment”. No direct interventions are required. The realities of the therapist’s interactions with the patient and the basic reality orientation of the patient always lead to the patient’s noticing discrepancies between the idealizing holding introject, based on the therapist and reflected in the transference, and the actual holding qualities of the therapist.

Each episode of awareness of discrepancy occasions disappointment, sadness, and anger. If each episode of disappointment is not too great, that is, is optimal, a series of episodes will ensue in which insight is developed and unrealistic idealization is worked through and relinquished. (Any disappointments that are greater than optimal precipitate recurrence of aloneness and rage in a transient regression that resembles phase I).

Ultimately the therapist as holding self-object is accepted as he realistically is: An interested, caring person who in the context of a professional relationship does all that he appropriately can to help he patient resolves conflicts and achieve mature capacities. Holding introjects come to be modified accordingly.”

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Discussion of Phase II

Here, Adler describes the progression that can occur after a stable, trusting relationship has been achieved in therapy. His main point is that, due to their childlike needs for dependence and support, borderlines tend to unrealistically idealize the therapist and view him as perfect during phase I, and that this idealization must eventually be made more more realistic in phase II. The introjects (mental representations) of the therapist that borderlines develop to comfort themselves are correspondingly unrealistic, and prone to breakdown under stress when others do not treat them perfectly.

To deal with this issue, Adler describes how the patient must gradually realize that the therapist is not a perfect parent, but is an actual therapist who is nevertheless sincerely interested in the patient. If the patient can come to see the therapist more realistically, as both good and bad, this carries over to relationships in the outside world. This intrapsychic progress helps the patient to be less sensitive to failures in empathy from other people, who will inevitably disappoint the patient from time to time. This process should occur gradually, so that the patient is not confronted too suddenly with the reality that his earlier idealizations were unrealistic.

In my view, the harder work, and in a way the more fundamental work, is what Adler describes in phase I. It is the work of Phase I – building a positive, trusting relationship and fully relaizing that one is not a bad person – that makes one no longer borderline. The work of phase II is also important, albeit easier. It is like building a base camp on a safe island (phase II) that one has reached after being shipwrecked and having to swim to shore in a stormy ocean (phase I).

Adler’s phase II can be compared to the later part of Seinfeld’s phase 3 and the early part of his phase 4.

Lastly, Adler describes a late phase in which the former borderline makes further progress:

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“To become optimally autonomous – that is, self-sufficient – in regard to secure holding and a sense of worth requires two developments: (1) A superego must be established that is not inappropriately harsh and that readily serves as a source of a realistically deserved sense of worth. 2) The ego must develop the capacity for pleasurable confidence in the self and for directing love toward itself that is of an affectionate nature. This development of the capacity to love the self contributes not only to enjoyment of being one’s self but also makes possible a reaction of genuine sadness in the face of losses that involve the self – accident, disease, aging, approaching death.

The therapeutic endeavors in phase III are based on the principle that capacities to know, esteem, and love oneself can be developed only when there is adequate experience of being known, esteemed, and loved by significant others.

Often, (formerly borderline) patients require help to gain the capacity to experience subjectively the factualness (validity) of their esteemable qualities, as well as the capacity to experience feelings of self-esteem.

In this phase of treatment, the ego evolves as its own resource for pride and holding through development of intrasystemic resources that are experienced as one part providing to another, both parts being felt as the self. These ego functions are developed through identifications with the homologous functioning of the therapist as a selfobject. That is, the therapist, verbally at times, but largely nonverbally, actually does provide the patient with a holding function, a function of loving in the affectionate mode of object love, a function of validating the patient’s competencies, and a function of enjoying the exercise and fruits of the patient’s competencies.

The experiential qualities of these newly gained ego functions might be expressed as follows:

1) “I sustain myself with a sense of holding-soothing,”
2) “I love myself in the same way I love others, that is, affectionately, for the qualities inherent in me,”
3) “I trust my competence in managing and using my psychological self and in perceiving and interrelating with the external world, hence I feel secure in my own hands,” and
4) “I enjoy knowing that I am competent and exercising my competence”

Total self-sufficiency is, of course, impossible. For its healthy functioning, the ego requires interaction with the other agencies of the mind as well as with the external world, and no one totally relinquishes use of others as selfobject resources for holding and self-worth, nor does anyone relinquish using selected parts of the environment (art, music, and so forth) as transitional objects. These dependencies are the guarantees of much of the ongoing richness of life.

It is only through the developmental acquisitions of phase III that the former borderline personality acquires genuine psychological stability.”

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Discussion of Phase III

In this passage, Adler’s compassion and positive outlook on human nature can be observed. Psychodynamic therapy is often criticized for over-focusing on what is wrong or pathological. Adler stands out in that he emphasizes what needs to go right in healthy emotional development.

In this phase, Adler describes how former borderlines can learn to love themselves affectionately and enjoy being themselves. He explains how crucial it is to feel loved and appreciated by others before a person can reciprocally do that for themselves. This phase could be compared to the later part of phase IV (Resolution of the Symbiosis) in Seinfeld’s phases.

To me, what Adler says here is self-explanatory and obvious. However, I expect that many people will be surprised to read such positive language about BPD. The public remains largely unaware that borderlines can become fully non-borderline, living normal lives in which they enjoy themselves. You don’t find this in the DSM!

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Adler’s View on the Validity of the BPD Diagnosis

During my contacts with Adler, I had a chance to ask him if he considered Borderline Personality Disorder a valid diagnosis. He answered that his main concern was helping people get better, and that he thought very little about diagnosis. He said that giving someone a diagnosis doesn’t tell you much about them, and that understanding their individual history and current problems is much more useful.

I pressed him to say something more about the BPD diagnosis. Adler said that he thinks it is useful for insurance reimbursement purposes, but not much else. Adler added that he sometimes wishes that the word “borderline” had never existed. He agreed with me that diagnoses like BPD have not been scientifically proven to be valid, but said it doesn’t really matter.

Adler added that he doesn’t view BPD as a fixed diagnosis, but rather as a subjective area along a continuum or spectrum of personality / emotional development. He defines BPD via the patient’s ego development – for example, by the relative presence or lack of self-soothing capacity, and by the degree of splitting – not by the other symptoms in the DSM. Adler joked that the DSM gets updated every few years to torture people like him who have to learn new diagnostic codes for insurance reimbursement.

On one of our phonecalls, I asked Adler if he thought BPD is cureable. He answered that “cure” is not the right word for BPD, since it implies the removal of a medical or physical condition, and connotes an idealized state where no problems remain.

But Adler did tell me that the majority of the borderlines he treated improved dramatically, and that many are no longer remotely borderline. He said he has worked with many former borderlines who have “largely worked it out and live good lives.” He emphasized that he was still very optimistic about borderlines doing well in long-term intensive therapy. Adler added that people in general are not “cured” in therapy. Rather, he said that no person becomes perfectly well or free from life’s challenges, but they can become better enough to live well.

Concluding Thoughts

There is much more in Adler’s book that cannot be discussed in the space here. For those interested, Adler’s book discusses the therapeutic alliance, how to handle borderline acting out, BPD’s relation to narcissistic personality and schizophrenia, the positive aspects of regression, hospital management, etc.

Two points will suffice to conclude this entry. The first is to reemphasize the importance of educating oneself about Borderline Personality Disorder. Understanding BPD psychodynamically gave me an advantage in planning my recovery and in understanding myself.

Borderline Psychopathology and Its Treatment was among the first of dozens of books I’ve read about BPD. Despite its age, its formulations are relevant to borderlines and their therapy today. Adler’s viewpoint on deficits in self-soothing capacity and positive introjects are not the only way I conceptualize BPD, but they are important.

The second is to remain skeptical. I do not agree 100% with Adler’s views. For example, I think he focused insufficiently on conflict (versus deficit) and on how internal bad objects operate in the mind of a borderline to actively block new positive relationships. Jeffrey Seinfeld and others write better on this topic. However, I get more than enough out of his work to like it and find it useful. That is the way to handle writings about BPD – take what is useful from them, and leave the rest.

I hope you, the reader, don’t blindly accept everything I say either. Although I know that BPD can be recovered from, I am not perfectly informed about nor do I have all the answers for BPD. Therefore, I encourage people to read widely about BPD online and offline, and to accept what feels right to them. Nevertheless, I hope people will benefit from reading some of Gerald Adler’s views on the condition. He is a great person, and I will miss him when he’s gone.